PRIORITY
SNOW REMOVAL REQUEST FORM
RESIDENT’S
NAME: _________________________
ADDRESS:
_________________________________
PHONE #:
__________________________________
The “EMERGENCY
& SPECIAL NEEDS” list for snow removal
will ONLY
include those
residents who have “life-threatening” conditions,
such as, but not limited to:
PLEASE CHECK
YOUR CRITERIA
*CHEMOTHERAPY/RADIATION __________
*DIALYSIS __________
*HOSPICE __________
*OTHER (SPECIFY) __________
APPOINTMENT DAY
& TIME DRIVER’S NAME
& ADDRESS
SUNDAY________________________________________________
MONDAY_______________________________________________
TUESDAY_______________________________________________
WEDNESDAY____________________________________________
THURSDAY_____________________________________________
FRIDAY_________________________________________________
SATURDAY_____________________________________________
DATE TREATMENT
IS OVER:______________________________
Doctor’s
Signature: _________________ Phone #: _____________________
Make
sure you have an ample supply of medication before a pending storm. Call 911 if
you require immediate emergency assistance.
IF YOU NEED TO BE PLACED ON THE SNOW PRIORITY LIST PLEASE RETURN THIS FORM
WITH A DOCTORS NOTE TO THE ASSOCIATION MANAGEMENT OFFICE.
THIS LIST MUST BE UPDATED EVERY YEAR.
PLEASE PROVIDE
INFORMATION EVEN IF YOU HAVE DONE SO IN PREVIOUS YEARS.