Canadian Farmers With Disabilities
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YES! COUNT ME IN!

Please complete this form to place your name on the

Canadian Farmers with Disabilities Registry

a CONFIDENTIAL list of farmers, family members or farm workers who have any type of permanent injury, illness, or disability. (Click Here for printable form)


Name:
 Address:(Street Number/Box Number)
City/Town
 Province
Postal Code
 Telephone
Fax
 Email
 
1. I am a:    Farmer    Spouse    Farm worker
 
2. Disability occurred in year: 
 
3. Did it occur:    on the farm?        off the farm?
 
4. Type of permanent disability.
 Loss of sight    Loss of hearing    Head injury    Paralysis    Permanent back injury
 Amputation. 
Specify 
 Permanent loss of mobility. 
Specify 
 Chronic Illness. 
Specify 
 Other 
Specify 
 
5. Type of accident:
Machinery
 Animal
Fire
 Electrical
Illness
 Other
 
6. Are you still farming?  Yes    No
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For more information, contact us at info@fwdcanada.com



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