APPLICATION

FORM
 





PARKING PERMITS FOR PERSONS WITH DISABILITIES

817 A Fort Street, Victoria, BC V8W 1H6
 

Fax: (250) 595-1512
Tel: (250) 595-0044

parking@drcvictoria.com

www.drcvictoria.com

Hours 9 AM to 4 PM

 

 

 




PART A: TO BE COMPLETED BY THE APPLICANT (please print clearly)

Have you applied for a DRC parking permit before? o YES o NO   If yes, Permit #

APPLICANT'S FIRST NAME(S)

 

FAMILY OR LAST NAME

MAILING ADDRESS

 

CITY                                          PROVINCE

 

POSTAL CODE

TELEPHONE NUMBER

DATE OF BIRTH   _______   _______   _______                   o FEMALE               o MALE

                                    YEAR     MONTH        DAY

PART B: CONDITIONS FOR PARKING PERMIT HOLDERS

·  It is the applicant's responsibility to ensure that his/her physician has completed PART D (on the back of this form). The applicant is responsible for ensuring this form is completed and for any changes made for its completion. All applications are subject to eligibility criteria.

·  Only one permit per Applicant will be issued. Permits issued for Permanent Disabilities must be renewed every three years. Temporary permits will be valid for a period of time as determined by your physician (maximum one year). All personal information will remain strictly confidential.

·  I agree to be responsible for the appropriate use of the permit. I understand that only I am permitted to use this permit. I understand the information above and hereby authorize the release of any information requested with respect to this application.

      ___________________________________________                  ________________

      SIGNATURE OR MARK (X) OF APPLICANT                                   DATE

      OR POWER OF ATTORNEY OR LEGAL GUARDIAN*

*Power of attorney/legal guardian to sign only if applicant cannot be responsible for a legal permit

TO BE COMPLETED IF SIGNED BY POWER OF ATTORNEY OR LEGAL GUARDIAN

FIRST NAME(S)

 

FAMILY OR LAST NAME

MAILING ADDRESS

 

CITY                                          PROVINCE

 

POSTAL CODE

TELEPHONE NUMBER

RELATIONSHIP TO APPLICANT

PART C: PAYMENT (if you submit this application by mail, do not enclose cash)

PROCESSING FEE IS $18 AT THE DRC or $20.00 BY MAIL o ENCLOSED - PAYABLE TO DRC

METHOD:      o Credit Card

o Cash          o Debit Card

o Cheque     o Money Order

o VISA                                                                                         EXPIRY DATE

o M/C         ____________________________                      ______/______

                            CREDIT CARD NUMBER                            Month  / Year

I ALSO WISH TO DONATE:

            $__________

                $__________                                                         

          THE AMOUNT I AUTHORIZE                             SIGNATURE

 

LAST NAME & INIT:

ISSUED BY:

SHADED AREA IS FOR DRC OFFICE USE ONLY

PERMIT #:

EXPIRES:

TYPE:               PERM.           TEMP.

PART D: TO BE COMPLETED IN FULL BY AN AUTHORIZED MEDICAL DOCTOR

CERTIFYING MEDICAL DOCTOR must complete this section. Please note: As the authorizing medical professional, you are verifying this applicant has a disability that will pose a risk to their health by walking 100 meters. Your authorization entitles them to special parking identification. Should there be misuse or abuse of the privileges associated with the issuance of this special identification, 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.

APPLICANT'S NAME (SHOULD BE THE SAME AS APPLICANT IN PART A - SEE REVERSE)

 

GIVE MEDICAL NAME OF CONDITION(S) CAUSING DISABILITY

 

 

HOW DOES THIS IMPAIR MOBILITY?

 

PLEASE DESCRIBE:__________________________________________________________________________________

____________________________________________________________________________________________________    

*PLEASENOTE: Should a temporary permit holder require a longer period of recovery, he/she will have to reapply for a permit after the date specified.
 
PROGNOSIS (please note: this section must be completed)

This patient is experiencing a mobility impairment that is (CHECK ONE ONLY):

o   PERMANENT  (Permit must be renewed every 3 years)

o   TEMPORARY

      If TEMPORARY, please give the date by which the disability is likely to cease*:

MONTH: ____________________ AND YEAR:  20_____.  MAXIMUM OF 1 YEAR.

CERTIFICATION

 

For the above reasons, it is my opinion that the patient has a mobility impairment that poses a risk to their health by walking 100 meters. I hereby certify that to my knowledge, the above information is true and correct.

 

_____________________________________                         ______________________

SIGNATURE OF THE MEDICAL DOCTOR                                                DATE

               Original signature required.

PHYSICIAN'S NAME (Please Print)

 

MSP #

ADDRESS STAMP

ADDRESS

 

CITY                                     PROVINCE

 

POSTAL CODE

TELEPHONE NUMBER

Please Note:

Persons who have sensory impairments are not eligible for a permit unless they also have reduced mobility.

If the answers to the following questions about a patient are "yes," the patient may be eligible for a permit:

 

-               Is the applicant’s disability classified as: neurological, musculoskeletal, cardiovascular, respiratory or other?

-               Given the applicant’s disability, does he or she have difficulty walking more than 100 meters?

-              Does the applicant require the use of any of the following mobility aids: manual wheelchair, motorized wheelchair, motorized scooter, or walking aid (such as cane, walker, or crutches)?