Complete this form and mail to: PROGRAM ASSISTANT ... OR Email â Email address: Address: Street address: City: Postal
Application form for medical exemption This form is for residents of Waterloo Region with a medical condition to apply for an exemption to the curbside collection garbage bag/can limit. To be eligible, applicants must: • Provide proof of living in Waterloo Region, and • Have a medical condition that is verified by a medical professional. Approved applicants will receive 30 regular garbage tags. To renew, an application has to be completed every year, as necessary.
For office use only Proof of residence checked & verified? Y / N Entered Application approved? Y / N Approved by:_________________________ Date Approved: _______________________ Garbage Tag Serial #s: _________________ Date Tags mailed: _____________________
Complete this form and mail to:
PROGRAM ASSISTANT “CONFIDENTIAL” Region of Waterloo Waste Management Administration Office, 925 Erb Street W., Gate 1, Waterloo, ON N2J 3Z4
SECTION 1: Applicant’s information Full Name:
First Name:_______________________________
Preferred contact method:
Phone – Phone number: __________________ OR
Address:
Street address: ___________________________
Last Name: ________________________________________ Email – Email address: ___________________________
City:______________________ Postal code: _____________
SECTION 2: Secondary Contact’s Information, if applicable.
Fill out this section if a family member or aide acting on behalf of the Applicant should be the main contact.
Full Name:
First Name:_______________________________
Last Name_________________________________________
Relationship to Applicant: ____________________
Preferred contact method:
Phone – Phone number: __________________ OR
Address: (If different than Applicant)
Street address: ____________________________
Email – Email address: ___________________________ City:______________________ Postal code: _____________
Please see other side for more instructions.
SECTION 3: Proof of current residence
Attach a scanned copy or photo of proof of your current residence, such as a utility bill or driver’s licence.
SECTION 4: Medical professional’s confirmation
Attach a note signed and dated by your medical professional (e.g. doctor, home care nurse) which includes your medical professional’s name, address and phone number, and acknowledges and certifies that you generate extra garbage due to a medical condition. This confirmation has to be renewed every two years. Exception: If the medical professional states that the medical condition is permanent and waste generated due to the condition cannot be reduced, The Regional Municipality of Waterloo staff will contact you to discuss the exemption and renew it as needed.
SECTION 5: Agreement - Terms and Conditions
I acknowledge that: • If the exemption is no longer required, I will notify the Region and return any remaining tags. I will not give away or sell the tags. • I will notify the Region if I move, and give the change of address. • I will use these tags to set out only non-hazardous medical waste such as dialysis tubing and incontinence products at my home following the Region’s collection requirements. • I understand that the Region may change the garbage bag/can limit and other curbside collection requirements. • I will not set out hazardous/bio-medical waste including syringes and unused medication for curbside collection. Instead, I will properly dispose of this waste at participating pharmacies or the Region’s Household Hazardous Waste depots. • I will endeavour to reduce my waste by fully participating in the Region’s Blue Box and Green Bin programs. • I have to renew this exemption application each year that I require and renew my Medical Professional’s letter of confirmation every two years, unless it is indicated that my condition is permanent and the amount of waste generated is constant. • By completing this application, I give the Region of Waterloo permission to contact me and my medical professional to certify that the information provided is true and accurate. In consideration of the acceptance of this application and the permission to participate in this program, I HEREBY UNDERTAKE TO COMPLY with all regulations and requirements as set out above and I HERBY RELEASE, WAIVE AND FOREVER DISCHARGE The Regional Municipality of Waterloo, including their Boards and Commissions and all Councillors, including the Chair, respective agents, officials, officers, and employees of and from all claims, demands, damages, costs, expenses, actions and causes of action, whether in law or equity, in respect of death, injury, loss or damage to persons or property UNLESS CAUSED by the negligence of The Regional Municipality of Waterloo or any of the aforesaid. Applicant’s signature:______________________________________ Date:_____________________ Notice with Respect to the Collection of Personal Information. Personal Information collected on this form is collected under the authority of the Municipal Act and handled in accordance with the Municipal Freedom of Information and Protection of Privacy Act. Your personal information will be used by staff of The Regional Municipality of Waterloo in the administration of the medical exemption for garbage tags. Questions regarding the collection, use, and disclosure of your personal information can be directed to: Cari Rastas Howard at 519-575-4400 ext.8412. • •
Please remember to attach all necessary documents. The Regional Municipality of Waterloo will not be held responsible for tags delayed or lost in the mail.
