Printable web-based Support Person Assistance Card Application Form

Fill out the form and email it to yourself to have the rest filled out by a regulated Health Care Professional.

Please complete the application and then print it out. Note you will not be able to save or submit the application below electronically. All fields are required unless marked with "(Optional)". Part C of the application will be included in your printed form; ask your healthcare professional to fill this out for you

The TTC Support Person Assistance Card is a photo identification card that identifies the card holder as a person who, because of disability, needs to be accompanied by a support person. A support person is someone who assists the card holder with communication, mobility, personal care/medical needs or with access to goods, services or facilities.

Important Note: Upon completing the form, you have the ability to email it to yourself. You may change the typed responses in the email form; however, if you leave off information that is mandatory, you may not be successful in obtaining the Support Person Assistance Card. Part A and C are to be filled out after the form has been printed out.

Part A: Eligibility Declaration

To be filled out by the applicant or the applicant's legal guardian. Please sign and date after prinitng. By completing, signing, and submitting this application to the TTC, I am stating that the information provided is true and accurate. I understand that submitting false information constitutes fare evasion and that fraudulent use of a TTC photo ID card is an offence under TTC By-law No. 1 subject to a fine and permanent loss of the ID card. I authorize the TTC 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 Legal Guardian (to be signed on the printed form) Date (please provide in year-month-day format in the following way: yyyy-mm-dd. Only use digits and dashes to fill in this field.)

Part B: Applicant Information

To be filled out by the applicant or the applicant's legal guardian. Unless stated otherwise, all fields on the form are mandatory. If the field contains the word "if", it is an optional field predicated and previous information provided in the form.

First Name Last Name Street Address Apartment or Suite Number (only if applicable) City Postal Code (please use letter-number-letter-space-number-letter-number format) Daytime Phone Number (please only provide the 10 digits and do not include any spaces, or parenthesis). If you do have an extension please provide the phone number in the following format: 10-digit phone number-space-ext-extension number. Evening Phone Number (Optional) Email Date of Birth (please provide in year-month-day format in the following way: yyyy-mm-dd. Only use digits and dashes to fill in this field.) Please explain the specific reason(s) why you need a support person (this field will allow up to 3000 characters)

Are you a registered Wheel-Trans Customer? Yes No If yes, what is your Wheel-Trans registration number? If yes, can you be left unattended at your destination? Yes No

Would you be willing to participate in a survey about the program? Yes No This application was completed by: Applicant Legal Guardian

Part C: Medical Information

These fields are to be filled out on the printed form but are included on this page to inform you of the fields necessary to be filled out by your regulated Health Care Professional.

Note: Must be completed by an authorized regulated Health Care Professional.

A regulated Health Care Professional is: a Family Doctor or other Physician, including Psychiatrist, Physiotherapist, Optometrist, Audiologist,Psychologist, Chiropractor, Occupational Therapist, Speech Language Pathologist, or Registered Nurse.

Name Professional Affiliation Professional Registration Number Street Address Suite Number City Postal Code Phone number Is the applicant's disability: Permanent Temporary If temporary, what is the expected duration?

I certify that the applicant is a person with a 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.

Signature of Medical Professional Date (please provide in year-month-day format in the following way: yyyy-mm-dd. Only use digits and dashes to fill in this field.): Stamp of Medical Professional

The personal information on this form is collected under the authority of the City of Toronto Act, 2006, S.O. 2006, c.11, Schedule A, and the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M.56, S.31. This information is collected and used for the purpose of the TTC Support Person Assistance Program, including ligibility determination and notifying applicants of any future changes to the Program. Questions about this collection can be directed to the TTC Customer Service Department, 1900 Yonge Street, Toronto, Ontario, M4S 1Z2, or by calling 416-393-3030.

For TTC Photo ID Office Use Only

Date Card Issued Card Number

Mailing Information

If mailing the application to the TTC, ensure that the following are enclosed: Completed application form (Parts A and B by the applicant or legal guardian, and Part C by an authorized regulated health care professional) Two (2) colour passport photos of the applicant, certified by the health care professional who completed Part C of the application Mail this application to: TTC Support Person Assistance Card 1900 Yonge Street Toronto, Ontario M4S 1Z2

Please allow 2 to 4 weeks processing time to receive the Support Person Assistance Card.