Non-Ambulatory - Physical Impairment Form

For the Town of Collierville Citizens only. This form is for Police and Fire Department use in the event of a fire or other emergency. Only citizens with impairments listed below need to fill out this form. We will perform an annual audit of all forms submitted. Please be sure to provide accurate contact information.

Name (*)

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Email (*)

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Address (*)

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Phone (*)

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Secondary Phone

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Type of Impairment (*)

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Are you an (*)

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Do you live alone?

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Location of bedroom or room where impaired individual stays most of the time:

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Name of Caretaker

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Caretaker's Address

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Caretaker's Phone

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Caretaker's Alternate Phone

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Additional Comments: (Such as type of ambulatory issue or other relevant information)

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All information obtained by the Collierville Police and Fire Department is confidential and will not be released under any circumstances without the expressed written permission of the applicant.

Please type in what you see (*)

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