Nintex Live Forms

Settings

Time zone

Safe Park Program (Individual Participant) Eligibility Application

Full Name of Vehicle Owner
*

Full Name of all vehicle occupants

Occupant 1 Name *

Occupant 2 Name

Application Contact Phone

(format 999-999-9999)

Application Contact Email Address *

Employment Location

Occupant 1 *

Occupant 2

On average, how many hours per week does each occupant expect to work

Occupant 1 *

Occupant 2

Alberta Health Care Number

Occupant 1 *

Occupant 2

Emergency Contact Information

Emergency Contact Name

(must be an individual not residing in the vehicle)

Emergency Contact Phone

(format 999-999-9999)

Emergency Contact Email *

The personal information you provide on this form is being collected by the Town of Canmore under the authority of section 33(c) of Alberta’s Freedom of Information and Protection of Privacy Act. This information will be used to administer programming for the Town of Canmore Safe Park Program. Your personal information is protected by the privacy provisions of the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection, use, or disclosure of this information please contact the Town of Canmore- Community Social Development department at 403.609.3743, or in person at 902 7th Ave (FCSS office), Canmore, AB, T1W 3K1.

I have read and understand the above FOIP Acknowledgement *

Program participants acknowledge their personal responsibility to know, understand, and adhere to current public health directives, this includes but is not limited to physical distancing requirements, gathering limits, and mask requirements. The Town of Canmore accepts no responsibility for persons who may contract COVID-19 or other infectious illness as a result of their use of the Safe Park Program.

I have read and understand the Public Health Acknowledgement *

I understand and agree that the Town of Canmore is permitting me to park my vehicle on a Safe Park Program lot. I understand that The Town of Canmore and Community Program Partners will not be responsible or liable for any damage, loss, theft (vehicle and/or contents) that occur or arise from this program. I fully understand and acknowledge that I am undertaking this activity at my own risk and expense, and I hereby release The Town of Canmore and Community Program Partners from any liability related to this program and hold harmless, indemnify, and release, and forever discharge The Town of Canmore and Community Program Partner and all its trustees, officers, representative(s), agents and employees from and against any and all claims, demands, and actions or causes of action, on account of damage to personal property, or personal injury, or death which may result from the Safe Park Program

I have read and understand the Liability Waiver *

I agree to adhering to all Safe Park participant responsibilities. I understand that if I or anyone in my vehicle fails to comply with the program Responsibility Agreement, I may be unable to participate in the Safe Park program, and any fees or deposit paid will not be reimbursed. I understand that the consequence of not complying with the Program Responsibility Agreement will be evaluated on a case-by-case basis. I understand that if the Program Responsibility Agreement is not adhered to then the Town will provide clear written documentation to program participants on areas of the non-compliance.

Click here to review the Program Responsibility Agreement

I have read and understand the Program Responsibility Agreement *

Do you have any questions or concerns related to the Safe Park Program?

Please upload the following documents

Copy of vehicle registration
Copy of vehicle insurance
Copy of driver's license
Proof of employment for (pay stub or employment contract)

Add Attachment

Thank you for your Application; the Town of Canmore will contact you shortly. Please note that only eligible applicants will be admitted into the program. The Town of Canmore reserves the right to disqualify any applicant who, in our opinion, does not fit with the purpose or goal of the program.

Applicant file number

Employer Name

Fee and deposit paid

Documentation Uploaded

Applicant Eligible

Applicant accepted into the program

Participant Start Date

Participant End Date

Participant Lot Location

Admin Notes