Special Care Form (English Only)

Brampton Fire and Emergency Services has a Special Care List that offers specialized assistance to residents who have disabilities, during an emergency.

To have your name or someone in your household added to the list, please complete the form below and return it to us. Once processed, the identified name(s) and address will be added to our Special Care List.

Please remember to:

  • Update your Special Care Form if there are any changes. Your form will be retained for a period of one (1) year from the date received.
  • Notify us if the “Special Care resident” no longer resides at the address stated in the form.
  • If you live in a high-rise building, notify your building’s management office as well so that they can add you to the building’s list of occupants who require special assistance. Note: This information is provided only to Brampton Fire and Emergency Services.

Choose one of three ways to submit your Special Care Form:

  1. Complete online form below
  2. Mail completed form to:
    • Brampton Fire and Emergency Services
      Communications Division
      8 Rutherford Road South, Brampton, Ontario L6W 3J1
  3. Fax completed form​ to: 905.456.5710
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Special Care Online Form

Please note: The fields marked * are mandatory.
Status
Occupants
Please provide details of other assistance required that is not checked off above.
Caregiver
(if applicable)
(if applicable)
(if applicable)
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Privacy Statement

The personal information on this form is collected under authority of the Municipal Act, SO 2001, c. 25, and will be used to provide assistance in the event of an emergency situation. Questions about the collection of personal information should be directed to Fire Communications Division, Communications Officer, 7750 Hurontario Street Brampton, ON, L6V 3W6, 905.456.5788