Application for accessible transit

Pour le français, cliquez ici.

Name

What is your year of birth?

Address

Name of nursing home (if applicable)

Telephone number(s)

Telephone number (1)

Telephone number (2)

Telephone number (3)

Email

Contact person name and phone number (this person could be contacted about your file and/or in case of an emergency)

Preferred language of correspondence

English

French

Why are you requesting the accessible transit service?

What is your current means of transportation without the accessible transit service?

Do you have people (family, friends, neighbours) who can provide you with transportation?

Yes

No

Have you considered public transit (Codiac Transpo)?

Yes

No

Are you eligible for or currently receiving a financial contribution from other sources for your travels? (For example, a subsidy from the Department of Social Development for travel to medical appointments.)

Yes

No

Uncertain

Please specify

Do you have a disability?

Yes

No

How would you rate your health condition?

Excellent

Good

Poor

What is the approximate number of trips (round trip) required per month?

How many of these trips do you consider as being essential?

Estimate the number of previously established trips by type of trip (per month):

Number of trips for medical reasons

Number of trips for employment or training purposes

Number of leisure trips

Number of trips for other reasons

Are you able to use the service by yourself?

Yes

No

Will someone accompany you when you use this service?

Never

Sometimes

Most of the time

Always

I agree that

My personal information be used by the municipality to communicate with me regarding the accessible transit service or to ensure the delivery of the service. I also understand and accept that the individuals I have identified as contact person may be contacted regarding my file or in case of an emergency.

137PO06.21
Personal information on this form is collected under the authority of the Right to Information and Protection of Privacy Act and the Personal Health Information Privacy and Access Act for the purpose of processing your application and for the delivery of the service. Questions about this collection of personal information can be directed to the Clerk, 333 Acadie Avenue, Dieppe, New Brunswick, E1A 1G9, 506.877.7900.