Non-Ambulatory - Physical Impairment Form

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.

First Name, Last Name, Middle Initial

Address

City, State, Zip

Home Phone

Second Phone

Type of Impairment

Blind
Hearing
Non-Ambulatory

Are you an

Adult
Child

Do you live alone?

Yes
No

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

Name of Spouse or Guardian:

Caretaker First Name, Last Name, Middle Initial

Address

City, State, Zip

Phone

Second Phone

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.

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The Town of Collierville does not discriminate on the basis of race, color, national origin, age, sex, or disability in its hiring and employment practices, or in admission to, access to, or operation of its programs, services, and activities pursuant to Title VI of the Civil Rights Act of 1964 (42 U.S.C. 200d) and the Americans with Disabilities Act of 1990, Pub. L 101-336.