Application for Support Person Pass

Customers with disabilities may need help when travelling on Durham Region Transit. The Support Person passallows a customer to bring someone with them toassist with communication, mobility or personal care or medical needs. The customer must paya valid fare but the Support Person travels free.

The Support Person pass is registered to the customer. Only one Support Person can travel with the customer at a time and does not need to be the same person. Customers must show the Support Person to the bus operator when boarding the bus.

The DRT Support Person card complies with the Accessibility for Ontarians with Disabilities Act, 2005 (AODA).

SECTION Amust be fully completed by the applicant or designate.

SECTION Bmust be fully completed by your registered health care professional.

Completed applications may be sent by mail, e-mail or fax to:

Durham Region TransitSpecialized Services

110 Westney Road South, Ajax, ON, L1S 2C8

Fax:905-619-9693

E-mail:

If you have any questions regarding this application or DRTservices, please call 1-866-247-0055 for Customer Service Assistance.

Approved applicants may be required to travel to a Region of Durham facility to process a photo ID card for the Support Person pass.

Please allow two to three weeks processing time to receive the Support Person Pass.

SECTION A:For Completion by Applicant or Designate

Date Prepared: ______☐New Application ☐Renewal Application

PLEASE PRINT CLEARLY

Mr☐Mrs☐Ms☐

First Name: Last Name:______

Date of Birth (Month/Day/Year):Gender:

Address: ______Apt/Unit #:

City: ______Province: ______Postal Code: _

Telephone: Home:Work: Extension:______

Cell:

Email address ______

Do you have a disability?

YesNo

Please explain why you need to be accompanied by a Support Person:

______

Signature of Applicant or Legal Gaurdian

I certify that the information provided in this application is true and correct. I understand that misinformation or misrepresentation of facts constitutes fare evasion and fraudulent use of DRT fare media, and will be cause for disqualification for a Support Person pass.

I authorize DRT to contact my health care professional and to receive additional information, including personal health information, if additional information, documentation or clarification is required to process my application.

Signature of Applicant or Designate: ______

Date (Month/Day/Year):______

This application was completed by:

Name: ______Relationship: ______

SectionB:For Completion by Health Care Professional

This section is to be completed by an authorized regulated health care professional including a licensed physician, Registered Nurse(RN), Physiotherapist,Registered OccupationalTherapist, Licensed Optometrist/Ophthalmologist, orCertified Rehabilitation Specialist.

Please Print Clearly

Name: ______Designation: ______

Address: ______

Telephone: Extension:

Iherebycertifythattheapplicant is a person with a permanent or temporary disability who, because of the disability, needs to be accompanied by a support person to assist with communication, mobility, personal/medical needs or with access to goods, services or facilities. I certify further that the information I have provided in this application is accurate and complete to the best of my knowledge.

Duration, if a temporary disability______

Health Care Professional’s Signature:

Date:______

Personal information on this form is collected under the authority of the Municipal Act, 2001, S.O. 2001, c.25 as amended, and is used solely to determine eligibility for a Support Person pass offered by the Region of Durham. This information is held in strict confidence.

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