Required fields are marked with asterisks (*)

Date of Application

Application for Eligibility for the Municipality of Dysart et al Special Transit Service

The DYMO Bus travels to five (5) areas within the County of Haliburton as well as specialized prebooked trips to Lindsay, Peterborough, Bracebridge, Barrie, Oshawa, Toronto and Kingston and provides Long Term Care Facility and Medical transfers.

You must be a resident of Dysart et al in order to apply.

Please answer all the questions on this form. This form should be completed by the Applicant or by an Authorized Designate on behalf of the Applicant.

Once received, the application will be reviewed within 14 calendar days and notification of eligibility will be sent to you. Please note that an incomplete application cannot be processed and will result in delays.

Part 1: Personal Contact Information of Applicant

Applicant Date of Birth:

Last Name:

First Name:

Middle Initial:

Residence Address:

Apartment Number:

Town or Hamlet:

Postal Code:

Mailing Address (If different from above):

Home Phone Number:

Cell Phone Number:

Work Phone Number:

TTY Number:

Email Address:

If the Applicant lives in a private home/apartment complex, please provide additional details regarding the address that will help the DYMO operator find the residence (i.e., name of apartment complex, directions from major roads, house colour, etc.)

Part 2: Emergency Contact Information

Primary Contact:

Name:

Relationship to Applicant:

Home or Cell Phone Number:

Work Phone Number:

Email Address:

Residential Address:

Mailing Address (If different from residential address):

Secondary Contact:

Name:

Relationship to Applicant:

Home or Cell Phone Number:

Work Phone Number:

Email Address:

Residential Address:

Mailing Address (If different from residential address):

Part 3: Applicant's Personal/Medical Information

Is the Applicant a current client of the DYMO bus service?

Yes

Is this the Applicant's first application to the DYMO bus service?

Yes

Is the Applicant a visitor who is temporarily living in the Municipality of Dysart et al?

Yes

Is the Applicant a registered client of the Canadian National Institute for the Blind (CNIB)?

Yes

Is the Applicant a client of another accessible transit system (apart from DYMO bus?)

Yes

Impairments/Medical Conditions

In the following section, please provide any relevant information about the Applicant's impairments that may affect their ability to board, exit and travel on a conventional public transit bus and/or conventional vehicle. Please be as specific as possible (i.e. exact impairment, abilities, etc.).

Impairment or Medical Diagnosis:

Approximate Date of Onset:

Previous and Current Treatments:

Possible or Planned Future Treatment:

Would you like to include a second impairment or medical diagnosis?

Yes

Please check the type(s) of transportation the Applicant is able to use with some support. Please check all that apply.

Accessible Passenger Bus (i.e. DYMO bus)

Adapted Personal Vehicle (when available)

Standard Taxi Cab (with support)

Other

Does the Applicant require a support person while travelling? A support person is a person specifically employed or designated by the Applicant to assist with their daily living needs, including travel.

Yes

Briefly describe the support the Applicant requires when travelling (i.e. must be lifted into vehicles, mobility aids must be placed into vehicles, assistance required to find their way around, visual display of bus stops, etc.)

*Please Note: DYMO bus may not be able to accommodate the Applicant if their wheelchair or scooter is longer than 48” (1.2 meters) or wider than 32” (81.3 cm) or if their total weight with their wheelchair or scooter is more than 1000 pounds (454 kilograms).

Can the Applicant transfer independently from a scooter or wheelchair to the seat of a bus?

Yes

Sometimes

Not applicable

Can the Applicant walk up and down one 11 inch (28 cm) step with a handrail without assistance from another person?

Yes

Sometimes

Part 4: Permissions and Protection of Privacy (to be read and signed by Applicant)

I understand that the purpose of this application form is to determine whether I am eligible to be a permanent, temporary or occasional client of Municipality of Dysart et al DYMO bus. I understand the personal/medical information provided on this form is confidential and will only be shared with designated employees of the Municipality of Dysart et al and/or the service provider Haliburton Bus Lines for the purpose of processing this application.

I give permission to designated employees of the Municipality of Dysart et al and/or Haliburton Bus Lines to contact either myself or the Authorized Designate who has completed this form on my behalf for further information to determine my eligibility for the DYMO bus.

I certify to the best of my knowledge, the information provided on this form is true and correct. I understand that providing false or misleading information could result in the termination of my eligibility for the DYMO bus service.

Personal Privacy:

The personal information collected on this form is subject to the provisions of the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and the Personal Health Information Protection Act (PHIPA). The information collected on this form will not be shared with anyone other than as set out in the previous consent above and will not be used for any purpose other than for eligibility and service delivery for the DYMO bus.

Signature of Applicant or Mark Witnessed by Authorized Designate

Clear

Was this form completed by the Applicant?

Yes

Form Builder

Application for Eligibility for the Municipality of Dysart et al Special Transit Service

Part 1: Personal Contact Information of Applicant

Part 2: Emergency Contact Information

Primary Contact:

Secondary Contact:

Part 3: Applicant's Personal/Medical Information

Impairments/Medical Conditions

Part 4: Permissions and Protection of Privacy (to be read and signed by Applicant)

Personal Privacy: