Collierville Police and Fire Departments

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 the following limitations need to fill out this form.


Type of Impairment:  Blind   Hearing    Non-Ambulatory

Last Name:  First Name: Middle Initial:

Adult:  Child:                                                                                Do you live alone?  Yes  No

Address:

Home Phone Number:  2nd Phone Number:

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

 

Name of Spouse or Guardian:

Last Name:  First Name: Middle Initial:

Address:

City:   State:   Zip:

Home Phone Number:  2nd Phone Number:

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

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.