Request for Accessible Accommodation

Required fields are marked with asterisks (*)

City of Kawartha Lakes
Human Services
Box 2600, 68 Lindsay Street North
Lindsay, ON K9V 4S7
705-324-9870
cklhumanservices@kawarthalakes.ca

Request and Verification for Accessible Accommodation

Last Name

First Name

Unit/Apt Number

Street Number

Street Name

Town:

Province

Postal Code

Home Phone Number

Work Phone Number (if allowed calls)

Cell Phone Number

Declaration and Consent: This section is to be completed and signed by the applicant, or if the applicant is less than 16 years of age, a parent or legal guardian.

I, the applicant, consent to my doctor verifying and disclosing the personal health information requested in this form for the purposes stated below. I declare the information given on this form is true and correct to the best of my knowledge. I have not knowlingly left out information or provided false information.

Date:

Doctor's Name:

Doctor's Phone Number:

Doctor's Fax Number:

Doctor's Mailing Address

Personal information contained on this form is collected pursuant to the Housing Services Act, 2011, and will be used for the purpose of responding to your request. Questions about the collection of this information should be directed to the City Clerk or Deputy-Clerk at 705-324-9411 extension 1295 or 1322.

Please complete the following questions in regards to your needs for accessible accomodation. Applicants and tenants are eligible for a modified unit based on a medical condition or disability. Most apartment buildings provide barrier-free features.

Do you have a medical condition or disability?

Yes

Are these impairments permanent?

Yes

Are your impairments caused by your medical condition or disability expected to get worse over time?

Yes

Please describe your physical limitations due to your medical condition or disability

What types of special needs do you or another member of the household have?

Inability to climb stairs because of a disability or medical condition?

Yes

Requires a unit in a building with an elevator because of a disability or medical condition?

Yes

Requires a unit with accessible modifications to support a person with moderate or severe physical disability

Yes

Requires a unit with accessible modifications to support a person using a wheelchair

Yes

Accessible Parking

Yes

What features are you or another member of the household applying for:

Wheelchair accessible (wider) doors or doorways

Yes

Lower kitchen cabinets and lower countertops

Yes

Automatic building entry doors

Yes

Accessible bathroom (roll under sink etc.)

Yes

Roll-in shower

Yes

Accessible Kitchen (roll under sink etc.)

Yes

Fire alarms for those who have a hearing impairment (strobe smoke detectors)

Yes

Unit features for those who have a vision impairment

Yes

Tell us about any other accessibility modifications the household member requires:

Additional comments or notes:

Existing equipment to support impairments:

Many of the accessible units have varying accessibility modifications. City of Kawartha Lakes - Housing Services staff work with applicants to assist them in applying for appropriate housing choices. Once the applicant receives an offer of housing for a modified unit, they should work with the Housing Provider to ensure that the specific unit meets their accessibility requirements.

For tenants currently in an accessible unit, regular verification of need is required to ensure legislative compliance.

Changes to your condition or need for accessible accommodation must be provided to our office within 30 days.

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City of Kawartha LakesHuman ServicesBox 2600, 68 Lindsay Street NorthLindsay, ON K9V 4S7705-324-9870cklhumanservices@kawarthalakes.ca

Declaration and Consent: This section is to be completed and signed by the applicant, or if the applicant is less than 16 years of age, a parent or legal guardian.

Please complete the following questions in regards to your needs for accessible accomodation. Applicants and tenants are eligible for a modified unit based on a medical condition or disability. Most apartment buildings provide barrier-free features.

What types of special needs do you or another member of the household have?

What features are you or another member of the household applying for:

For tenants currently in an accessible unit, regular verification of need is required to ensure legislative compliance.

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City of Kawartha Lakes
Human Services
Box 2600, 68 Lindsay Street North
Lindsay, ON K9V 4S7
705-324-9870
cklhumanservices@kawarthalakes.ca