Driveway Snow Windrow Clearing Medical Application

Medical/Health Practitioner Professional Information:

Name:

License/Certification Number:

Address:

Telephone:

Fax Number:

Email:

Medical/Health Practitioner Professional Information:

Licensed Physician

Licensed Physical Therapist

Registered Nurse (or RPN)

Registered Occupational Therapist

Medical/Health Practitioner Professional Information:

Licensed Chiropractor

Certified Rehabilitation Specialist

Certified Psychologist/Psychiatrist

Licensed Optometrist/Ophthalmologist

Other (Specify):

Does this person have a physical disability or medical condition that impacts their ability to shovel their driveway during/after a snow event? Please Explain.

Medical/Health Practitioner Signature:

Clear

Date:

Information collected on this form shall be used for the sole purpose in which it is intended/collected and shall remain confidential and subject to the Municipal Freedom of Information and Protection of Privacy Act.