Town of Webster Department of Engineering 1000 Ridge Road, Webster, NY 14580-2917 • 585-872-1000 • Fax: 585-872-1352 Engineering@ci.webster.ny.us
REQUEST FOR CHILD WITH DISABILITIES WARNING SIGNAGE Date: Name of Applicant (Parent/Guardian): Applicant Address: Applicant Phone Number:
Applicant Email:
Child’s Date of Birth: Type of Sign Requested (check one below): ___ Deaf Child Area
___ Blind Child Area
___ Child with Autism
W11-2 & NYW11-2P Applicant must include a note from the child’s pediatrician/doctor attesting to the child’s condition. Applicant will verify with the Engineering Department annually the child maintains residence at the location on the application. Undersigned parent/guardian hereby agrees that, if singing is granted, I will advise the Town of Webster in the event that the child moves from the address listed above. Parent/guardian further acknowledges that, at the time of this application, signage is limited to children under 18 years of age per Federal and State guidelines. The City will remove the signage after the child’s 18th birthday. Signature:
Date:
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Town of Webster Department of Engineering 1000 Ridge Road, Webster, NY 14580-2917 • 585-872-1000 • Fax: 585-872-1352 Engineering@ci.webster.ny.us
Child with Disabilities Warning Sign Checklist for Applicant: Completed Application Note from Doctor
INTERNAL USE ONLY Criteria for approval to be met: •
Child with Autism is under the age of 18
•
Average daily traffic volume is less than 2,000 vehicles
•
The speed limit is 35 MPH or less
•
Roadway is residential in nature
APPROVED
DISAPPROVED
Reason:
Signature:
Date:
Manual of Uniform Traffic Control Devices (MUTCD) NYS Supplement to the MUTCD NYSDOT Child with Autism 5.4.20 Ttile 17 NYCRR-DOS City of Buffalo
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