Required fields are marked with asterisks (*)

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

Part 2: Emergency Contact Information

Primary Contact:

Secondary Contact:

Part 3: Applicant's Personal/Medical Information

Is the Applicant a current client of the DYMO bus service?
Is this the Applicant's first application to the DYMO bus service?
Is the Applicant a visitor who is temporarily living in the Municipality of Dysart et al?
Is the Applicant a registered client of the Canadian National Institute for the Blind (CNIB)?
Is the Applicant a client of another accessible transit system (apart from DYMO bus?)

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.).

Would you like to include a second impairment or medical diagnosis?
Please check the type(s) of transportation the Applicant is able to use with some support. Please check all that apply.
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.
Please check the type(s) of mobility aids the Applicant uses when travelling in the community. Please check all that apply.

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

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.

Was this form completed by the Applicant?

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