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Vulnerable Children Signage Application Form

The Vulnerable Children Signage Policy is designed to improve awareness for the safety of children, particularly those with disabilities, who are near or adjacent to roadways. The program includes the installation of a “Vulnerable Children Warning” sign, a traffic sign intended to alert motorists to the presence of vulnerable children in residential neighbourhoods and encourage increased caution.

Warning signs may be installed upon request by the parents or legal guardian of the Vulnerable Child provided they supply the Town with the requested information below.

Applicant Information

First and Last Name

Street Address

Unit/Lot/Condo Number

Town

Postal Code

Province

Phone Number

Email Address

Vulnerable Child Information

Child's Name (First, Last)

Child's Birthdate (dd/mm/yyyy)

Child's Disability

Declaration of Applicant

By signing this application, the applicant agrees to the following as approved by Town Council in accordance with the Town’s Vulnerable Children Signage Policy number 039.

As Applicant I am the parent and/or legal guardian or otherwise having lawful custody of the Child identified in this Application
I acknowledge and agree that the sign will only remain in place for a predefined period of five (5) years or when the child reaches the age of sixteen (16), whichever occurs first, or as determined by the Director of Infrastructure acting reasonably. It is the responsibility of the applicant to reconfirm the need for the sign after the 5 year period.
I acknowledge and agree that: 1) the posting of a requested sign is no assurance of child’s safety at any particular time nor that safer conditions now exist in the area in the vicinity of the requested sign; 2) The child’s safety remains the sole responsibility of the parent/legal guardian(s) and 3) There is no substitute for proper supervision and education as it relates to safety and traffic.
I acknowledge and agree that The Corporation of the Town of Essex shall not be held liable nor have liability with respect to and as Applicant/Parent/legal guardian and on behalf of the Child I hereby waive, release and agree not to sue the Corporation of the Town of Essex for any special, indirect, incidental or consequential damages that may be suffered or incurred arising out of, or in any way related to this Application.
I consent to the collection/use/disclosure of the personal information provided in this application, such information as may be reasonably necessary to perform the services contemplated by this application or for such other lawful and necessary purposes.
I will notify the Town of any positive changes in the child’s impairment that may warrant the removal of the sign.
I will notify the Town in a timely manner of any relocation to another place of residence. The sign may be relocated to the new place of residence if deemed eligible by the Director of Infrastructure Services.

Signature of Applicant

Clear

Date

Please upload a copy of proof of child’s age (ie. birth certificate, passport, health card) and a copy of a physician’s statement confirming the disability.

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