|
Please
complete and return 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. Name:
Address:
(Box # or Street address)
Town/City:
Province: Postal
Code: Phone:
Fax:
1. I am a Farmer,
Spouse,
or 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
Amputation. Specify
Head injury
Paralysis
Permanent back injury
Permanent
loss of mobility. Specify
Chronic
Illness. Specify
Other
5.
Type of accident:
Machinery
Animal
Fire
Electrical
Illness Other
Are you still farming? Yes No
Please
forward to: Canadian
Farmers With Disabilities Registry Carl
Palmer, Chairperson R.
R. 1 Aylesford, NS B0P
1C0 Ph:/Fax: (902) 847-9420 |
