Parking Program For People With Disabilities Form Page 2
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2SECTION 2
MEDICAL INFORMATION
Applicant's Name:________________________________
Completed by a Physician, Occupational Therapist, Physical Therapist, Nurse Practitioner or Chiropractor.
PLEASE PRINT CLEARLY
Medical name(s) of disabling condition(s): __________________________________________________________________
In layman terms, please describe how this condition impairs the applicant's mobility: ________________________________
Check one of the following three highlighted durations:
Short term disability where the applicant is unable to walk unassisted for more than 50 metres (164 feet) without great
difficulty or danger to their health and safety but where the nature of the condition is temporary (example: broken leg).
Specify estimated length of the condition in number of months (1-12 months maximum) ______ Months.
Long term disability where the applicant is unable to walk unassisted for more than 50 metres (164 feet) without great
difficulty or danger to their health and safety but where the disability may improve within the next 3 years (example:
improvement may result due to therapy, surgery, treatment). The applicant will be required to re-apply should an
extension be required.
Permanent disability where the applicant is unable to walk unassisted for more than 50 metres (164 feet) without great
difficulty or danger to their health and safety and the disability is of a permanent nature and will not improve within the
next 3 years. The applicant will be able to self-declare to renew their permit and will not require verification from a
healthcare professional. To be eligible for a permanent parking permit:
The applicant uses a wheelchair to travel any distance.
The applicant uses a mechanical aid to travel any distance. The mechanical aid is: (check one)
Scooter
Crutches
Walker
Cane
Lower Limb Prosthetic Device
Other - specify: _______________________________________________________________________________
The applicant has a permanent disability which is not visible such as chronic obstructive pulmonary disease
(COPD), cardiovascular disease, or other permanent condition whereby walking a distance of 50 metres (164 feet)
would pose a further risk or endanger their health. Specify risk to health: ________________________________
As the authorizing healthcare professional, you are verifying the applicant has a physical disability that will pose a
Note:
risk to their health by walking a specified distance. Should there be misuse or abuse of the privileges associated
with the issuance of this permit, you may be requested to verify the applicant's disability. The applicant is
responsible for any and all costs incurred in the completion of this application.
Healthcare Professional's Name & Address (Print or use office address stamp)
Full Name:
Telephone Number:
Medical Office Stamp
Address:
Fax Number:
City/Town:
Postal Code:
Professional Designation:
Physician
Occupational Therapist
Physical Therapist
Nurse Practitioner
Chiropractor
Certification: It is my opinion that the applicant is eligible for a parking permit under the criteria described above.
Signature of Healthcare Professional
Date
1337-15
Page 2 of 2
06/2012
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