Form Builder

Update of personal information

Gender

Mr.
Mrs.
Other

Si autre

First name

Last name

Client number

Date of birth

Adresse de résidence

Address

Apt

City

Postal code

The postal code must be in the following format: X0X 0X0

I agree to receive information or offers from my paratransit organization

Phone number(s)

Home
Mobile
Work

Home number

The telephone number must be in the following format: 111 111-1111

Mobile number

The telephone number must be in the following format: 111 111-1111

Office number

The telephone number must be in the following format: 111 111-1111

Can be left alone (cognitive impairment, intellectual disability, Alzheimer's)

Can the client be left alone?

Note:

Une personne qui n’est pas autonome ne peut rester seule sans surveillance. Le chauffeur doit s’assurer qu’un responsable prenne en charge la personne avant de quitter les lieux.

A person who is not autonomous cannot be left alone without supervision. The driver must ensure that an accountable person takes charge of the client before leaving the premises.

Medical condition

Are there any changes in the medical condition affecting the ability to travel with paratransit?

Mobility aids

What mobility aids are used regularly to facilitate outdoor travel?

Dimensions of the manual, motorized, three-wheeled or four-wheeled wheelchair

Dimensions

1 - Maximum height (from the ground to the highest element)

2 - Maximum length

3 - Maximum width of the chair

Emergency contact

First name

Last name

Phone number(s)

Résidential
Cellphone

Home Telephone number

The telephone number must be in the following format: 111 111-1111

Mobile number

The telephone number must be in the following format: 111 111-1111

Add a contact

Yes

First name

Last name

Phone number(s)

Residential
Cellphone

Home Telephone number

The telephone number must be in the following format: 111 111-1111

Mobile number

The telephone number must be in the following format: 111 111-1111

I certify that the information provided is correct.