Accessible Transit Registration Form

Registration Form

North Grenville Accessible Transit
The information obtained in this application process will be used by the Municipality of North Grenville to assess the applicant’s eligibility for the specialized transit service. All information contained in the application will be kept confidential. The Municipality will provide the Operator with a list of eligible riders, containing the riders name only.
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City Province

Postal Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name

First Name Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Do you have a disability as defined by AODA?

Yes No
If yes, is the disability:

Unconditional All trips require specialized service, for example a permanent disability. Temporary(up to one year) – All trips require specialized services for a limited duration, for example during recovery from surgery. Conditional(May to September or October to April)–Trips taken by a person with a disability who requires specialized services under certain circumstances, such as extreme weather conditions.
Are you 65 years of age or over?

Yes No
Do you require a support person to ride with you?

Yes No
Would you like to receive your approval notification by:

email phone
Signature

Clear
By providing your signature you attest the information you have provided is accurate and complete to the best of your knowledge.

The information provided in this form is collected under the Municipal Freedom of Information and Protection of Privacy Act. Personal information on this form will be used to determine your eligibility for accessible transit services and to provide you with appropriate transit services. We may contact you to notify you of accessible transit service changes. We will also use de-identified data to compile statistical information for program planning.

Questions regarding the collection of this information and how it is used may be directed to 613-258-9569 ext. 133
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