Fillable Application for Medical Exemption approved? Y / N (Dufferin County)

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Application for Medical Exemption approved? Y / N (Dufferin County)

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Address:
Application for
Medical Exemption
The County of Dufferin will consider exempting
residents who are either not able to meet their
weekly bag limit, or who require an additional
privacy bag, due to waste generated stemming
from a medical or health related situation of a
resident of that property. Approved applicants
will receive bag tags to cover one (1) extra
garbage bag or privacy bag a week for a period
of six (6) months. An application must be
completed every six months for continued
service.
Please complete/include the following:
• Pages 1 and 2 of this form
• Proof of current residence
Please return to Dufferin County Waste Services in one of the following ways:
• Online: www.dufferincounty.ca/waste
• Mail or drop-off: 55 Zina Street (2nd floor), Orangeville, ON L9W 1E5
• Email: dufferinwaste@dufferincounty.ca
Date of Application: Name of Applicant: Telephone Number:
Address of Property:
Are you the owner of the property?
YES NO
If not, please provide contact information for the owner/property manager.
Name of Property Owner: Telephone Number:
Approved by:
Date Approved:
Bag Tag Serial
#s:
Comments:
Privacy Bag? Y / N
Bag Limit? Y / N
Proof of residence checked & verified? Y / N
Application
approved? Y / N
Entered
OFFICE USE ONLY
Requested Exemption:
increase of one (1) garbage bag to the weekly bag/container limit. Only wastes from the
medical condition will be placed in the extra clear bag/container, with bag tag affixed.
or;
increase of one (1) privacy bag within each bag placed out for collection. Only wastes
from the medical condition will be placed in the extra privacy bag, with the special bag
tag affixed to the outer clear garbage bag/container.
Briefly explain the medical/health related situation:
Terms and Conditions (please check each box, to confirm you have read and accept these terms and
conditions):
I acknowledge that this allowance is due to a medical/health related situation only.
Only wastes from the medical condition will be placed in the extra privacy bag or clear garbage
bag/container (depending on requested exemption), with the bag tag affixed to the outer clear
garbage bag/container.
Examples of Medical Wastes (non-hazardous) include (but are not limited to): Intravenous
Waste, Medical Packaging Materials, Colostomy Tubing, Incontinence Products, and Dialysis
Tubing.
The County does not accept hazardous bio-medical waste such as syringes, hypodermic
needles and sharps. These hazardous wastes should be disposed of properly through syringe/
needle return programs at participating pharmacies, or through the County’s Household
Hazardous Waste Events (in sturdy/puncture proof plastic containers).
The tags are for use by the above noted resident only, and cannot be transferred or re-sold. The
bag tags hold no cash value.
If the exemption is no longer required, I will notify the County and return any remaining tags.
I will notify the County if I move, and give the change in address.
I also acknowledge that participation in Dufferin County’s Blue Box and Green Bin programs is
required under the Waste Services By-law, and agree to fully participate in these programs, if
approved for an exemption due to medical needs.
I certify that the information provided is, to the best of my knowledge, correct and complete.
Signature (not required for email submission below):
Date:
Submit Form By Email
Print Form
Notice with Respect to the Collection of Personal Information
Personal information requested on this form is collected as a necessary part of the administration
of Waste Services by the County of Dufferin pursuant to its legal authority as set out in the
Municipal Act, 2001. Collection, use and confidentiality of the personal information will be
according to the standards of the Municipal Freedom of Information and Protection of Privacy
Act and the information will be used for the purpose of verification of eligibility for specialized
set out service programming only. Questions or concerns about collection, use or disclosure of
personal information should be directed to the Director of Public Works at 519-941-2816 ext.
2600.
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Application for Medical Exemption approved Y N (Dufferin County)

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Completed 8 April 2021

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