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2. Program Guidelines

   The Village of Palmetto Bay’s Sleep Safely Program is available to all Village seniors.  Simply fill out the online form and pick up your bed rails at Village Hall, during regular business hours, which are Monday to Friday from 8:30 am to 5 pm.  You must show proof of age and residency in Palmetto Bay to pick up your rails.  More details are provided in the Eligibility section below.

4. Program Eligibility Requirements
   • Must be a senior 65 years of age or older
   • Must be a resident of the Village of Palmetto Bay
   • Must sign a Release and Hold Harmless Agreement

   To pick up your bed rails, please bring with you an ID card as proof of your age and address.  A driver's license or other government-issued ID showing your birthday and address is also acceptable.  If you are picking up a set of bed rails for a senior resident, you MUST bring your own picture ID AND the resident's picture ID.

   In addition, the person picking up the rails will be required to sign a Release and Hold Harmless Agreement.  The Release and Hold Harmless Agreement can be found on the program webpage. 

6. First Name*

   Please enter the applicant's first name.

7. Last Name*

   Please enter the applicant's last name.

9. Email Address
10. Home or Mobile Number*
12. Home Address*
14. City*
15. State
16. Zip Code
18. Applicant's Age*

    Is the applicant 65 years of age or older?

    1. Yes
    2. No
20. (Optional) Are you a veteran?

    1. Yes
    2. No
22. Special Conditions/ Disclaimers
    • The Village of Palmetto Bay will not install the bedrails.
    • The Village of Palmetto Bay is not recommending any seller or installer of bed rails.  
    • Any defects or problems with the bed rails or installation must be directed to the seller, manufacturer or installer.
    • The Village is not providing any express warranty, or any implied merchantability or a warranty of fitness for a particular purpose of the product and there is no guarantee regarding the work and installation of the product.
    • As a condition to participate, the recipient is required to sign a Release and Hold Harmless Agreement provided by the Village of Palmetto Bay, which indemnifies and holds harmless the Village and its officers, employees, agents and instrumentalities from any and all liability, losses or damages.
24. Initials*

    By initialing above, you agree to the terms and conditions of the program.

26. Date and Time of Submission*
    Date and Time of Submission

    Date and Time of Submission
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field