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ROLLS Specialized Transit Service Application

Please enter your full name:

Your full residential address:

What is the best phone number to reach you at?

Email address:

If "other" location chosen for transit services, please explain

What frequency will you require transit services?

If your disability is temporary how long do you anticipate requiring transit service for?

Do you use a wheelchair?

Yes

Do you walk with an assistive device?

Yes

Do you travel with a companion?

Yes

Emergency Contact (name and phone number)

The name of your attending medical professional and profession:

Contact phone number for your authorizing medical professional:

Please upload letter confirmation authorizing the need for specialized transit completed by your attending medical professional (e.g. Physician, Registered Nurse, Physiotherapist, Chiroprator, etc. )

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

A copy of the medical professionals note can also be mailed or dropped off to the address provided if you are unable to attach in the space above.

5 Mill Street South, Port Hope, ON L1A 2S6

Applications will not be reviewed or approved until valid note from your attending medical professional is received.

I hereby apply for ROLLS and certify that I am unable to use regular public transportation because of my physical disability.

Date of submission:

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ROLLS Specialized Transit Service Application