Fill - Free fillable SPECIAL RESERVED PARKING SPACE PROGRAM (Conshohocken Borough) PDF form

SPECIAL RESERVED PARKING SPACE PROGRAM

Program Policy, Criteria for Award, Procedures and Terms

POLICY:

The Borough of Conshohocken has established the criteria listed below as a general guideline and

procedure to be utilized when resident requests are made for special parking privileges.

CRITERIA:

The criteria to be examined by the Borough in assigning “Special Reserved Parking Spaces” are as

follows:

The applicant or, if different, the vehicle owner, must demonstrate that he or she is

a licensed driver and has either a handicapped license plate or a handicapped

placard issued by PennDOT. Provide a copy of license & placard. If the owner of

the vehicle is a person other than the applicant, the owner must reside

at the

same location as the applicant and must submit a copy of the vehicle registration

to verify owner’s residence.

2. Appropriate medical evidence and records: the applicant shall submit a written

statement from a treating physician, including a description of the applicant’s

physical condition, the limitations on mobility due to such condition, and the

expected duration of the need for a special reserved parking space.

3. Impact on the neighborhood and surrounding community if the request were to be

granted.

4. Is the request directly related to a severe hardship, which in some way seriously

restricts the mobility and ambulatory functions of the applicant?

5. Are there options available to the homeowner/resident such as off-street parking,

alleyway parking and the like, which could resolve the applicant's hardship?

6. An examination of the personal circumstances of the applicant including

retirement status, driving ability and other like factors.

7. Applicant will be given an opportunity to meet with the Special Parking

Committee and orally present his or her request, should the application be judged

to fall outside of the program criteria.

PROCEDURES:

The procedure to be followed in dealing with requests for a special reserved parking space as

follows:

1. The application for a Special Reserved Parking Space will be submitted to assigned

staff at the Conshohocken Borough Administration Office.

BOROUGH OF CONSHOHOCKEN

400 Fayette Street, Suite 200 Conshohocken, PA 19428

Phone (610) 828-1092 Fax (610) 828-0920

2 Borough staff will assess the application in terms of the criteria established for the

Special Reserved Parking Space Program. A determination will be made regarding

the provision of the requested reserved space.

3. A full report of the review and determination of whether or not the applicant

meets the program criteria will be forwarded to the Council Person in whose Ward

the applicant’s property is located.

4. Where a determination has been made that the applicant does not meet the criteria

for a Special Reserved Parking Space, a meeting with the Special Parking

Committee will be scheduled, at which time the applicant may orally present the

Committee with his or her reasons why a Special Reserved Parking Space should

be approved. The Committee may, in its discretion, either grant or deny the

application based upon the applicant’s presentation and after consideration of the

circumstances presented. The Committee shall render its decision and notify the

applicant immediately following the applicant’s presentation, or shall notify the

applicant in writing no later than five (5) days after the meeting.

5. The decision of the Special Parking Committee will be forwarded to Conshohocken

Borough Council.

6. In the event that the Special Parking Committee denies an application for a Special

Reserved Parking Space, following the applicants presentation, the applicant may

appeal the denial to Borough Council, in writing, within ten (10) days of the

Committee’s action, if taken at the Committee’s meeting, or within ten (10) days of

the date of the Committee’s written notification to applicant that the applicant was

denied. Borough Council shall consider the appeal no later than forty-five (45)

days after receipt of the appeal.

7. Following a determination that a Special Reserved Parking Space should be

granted relevant information will be forwarded to the Superintendent of Public

Works for sign installation.

8. The exact location of the reserved space and its signage, in front of the applicant’s

residence, shall be determined by the Conshohocken Public Works Department.

TERMS:

Terms of the Special Reserved Parking Space Program are as follows:

1. The initial term of the special parking space is one (1) year.

2. After the initial term, a yearly renewal certification must be filed and all

information verified

SPECIAL RESERVED PARKING SPACE PRO

GRAM

Date: __________________

Applicant Name: ______________________________________________________________________

Telephone Number: (____________) _____________________________________________________

Address: _____________________________________________________________________________

City, State Zip:_________________________________________________________________________

Name of Individual in Need of Special Reserved Parking: _________________________________

Address at which the reserved parking space is to be installed:

______________________________________________________________________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS:

1. Please describe any physical condition which supports your request for a reserved

parking space:

___________________________________________________________________________________

2. Explain why you need a reserved parking space:

___________________________________________________________________________________

3. Do you use any assistive devices:

� Yes � No

If yes, what devices do you use?

________________________________________________________________________________

5. D

o you have a garage or other off street parking available:

� Yes � No

6. License plate number of the vehicle to occupy the special reserved space:

___________________________________________________________________________________

BOROUGH OF CONSHOHOCKEN

400 Fayette Street, Suite 200 Conshohocken, PA 19428

Phone (610) 828-1092 Fax (610) 828-0920

7. In whose name is this vehicle registered: __________________________________________

8. Does the vehicle have a handicapped license plate or use a handicapped placard:

� Yes � No

9. If the vehicle is not registered to the individual in need of the special reserved parking

space, please explain why a special reserved parking space is needed:

___________________________________________________________________________________

Applicant’s Signature: ______________________________________ Date: _____________________

400 Fayette Street, Suite 200 | Conshohocken, P

A 19428|Phone: (610) 828-1092|Fax:

(

610) 828- 0920|www.conshohockenpa.org

(attach a copy of placard if used)

(attach a copy of registration)

Return to: Borough of Conshohocken

Attn: Specially Dedicated Parking Space Program

400 Fayette Street, Suite 200

Conshohocken, PA 19428

phone: 610-828-1092 fax: 610-828-0920

EDICAL QUESTIONNAIRE

(To Be Completed By a Physician)

Date: __________________________________ Physician: __________________________________

Patient: _________________________________ Diagnosis: __________________________________

Physical Capacities and Limits:

Standing __________ Hours Sitting __________ Hours Walking __________ Hours

Lifting __________ Hours

☐Light Work: Lifting 10-20 Pounds Maximum

☐Medium Work: Lifting 25-50 Pounds Maximum

☐Heavy Work: Lifting 50-100 Pounds Maximum

Yes No How Often

Driving ☐ ☐ __________

Reach Overhead ☐ ☐ __________

Position Change ☐ ☐ __________

Climb ☐ ☐ __________

Bend from Waist ☐ ☐ __________

Squat/Stoop ☐ ☐ __________

Push/Pull with Legs ☐ ☐ __________

Medications taken at present: __________________________________________________________

Are Special Parking Privileges Necessary: ☐Yes ☐No

Physicians Comments:

______________________________________________________________________________________

Does Patient Work? ☐Yes ☐No If yes, describe work: ________________________________

Date Patient Last Seen: _________________________________

I, the undersigned physician, verify that the statements contained herein are true and correct to

the best of my knowledge, information and belief. I also understand that the statements herein are

made subject to the penalties of 18 PA CS Section 4904 relating to unsworn falsifications to

authorities.

___________________________________

Physicians Signature

BOROUGH OF CONSHOHOCKEN

400 Fayette Street, Suite 200 Conshohocken, PA 19428

Phone (610) 828-1092 Fax (610) 828-0920

Authorization for Release of Personal Health Information

Important Information Regarding Your Rights

• You may refuse to sign this form.

• Signing this form may not be considered a condition of enrollment, or a requirement to

receive benefits.

• This authorization may be revoked anytime prior to its expiration date by notifying the

company or companies named below in writing. The Revocation will not have any

effect on actions taken or information provided prior to the receipt of the revocation.

• The company or companies named below may re-disclose the information provided

pursuant to this authorization. However, you have the right to seek assurances from the

company or companies that the information will not be re-disclosed.

Any facsimile, copy or photocopy of this authorization shall authorize you to release the

records requested herein. This authorization shall be in force and effect until two years from

date of execution at which time this authorization expires.

Information Regarding the Use and Disclosure of Your Personal Health Information

I authorize the use of disclosure of my individual identifiable health information as described

below. I understand that this authorization is voluntary and that I may revoke it at any time by

submitting a revocation in writing to the persons/organizations providing this information.

Patient Name: _____________________________________ ID Number: _______________________

Persons/organizations authorized to provide the information: ______________________________

______________________________________________________________________________________

Persons/organizations authorized to receive the information:

Conshohocken Specially Dedicated Parking Space Program

Specific description of information to be used or disclosed:

Any and all information to support the need for a dedicated parking space.

Signature of patient or patient’s representative: ___________________________________

Date: ___________________________________

Printed name of patient or patient’s representative: ___________________________________

Daytime telephone of patient or patient’s representative: _______________________________

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