Calgary Transit Access Application: Should I Apply?
Calgary Transit Access Application: Should I Apply?
Calgary Transit Access Application: Should I Apply?
TS 5265 (R2019-02)
SHOULD I APPLY?
Calgary Transit Access is a shared ride, door to door public service for Calgarians who
are prevented from using Calgary Transit due to a disability.
Please note that submission of an application does not guarantee eligibility for services.
Updated information and/or an interview will be required periodically to renew eligibility
for services.
• Calgary Transit continues to improve accessibility. Because of this, eligibility in the past does not
guarantee eligibility in the future.
• Please ensure the form is complete and legible.
• Please provide a copy of the Applicant’s photo identification with proof of address and attach
it to this form.
• Part G must only be completed and signed by one of the licensed health care professionals that
has directly supported the Applicant, as listed on Part G.
• Part G cannot be filled out by a friend, acquaintance or relative.
• Any fees for the completion of this form and/or any additional information are the
responsibility of the Applicant.
• Upon receipt of completed form, the applicant will be contacted within 10 business days to
arrange an in-person interview at one of the Calgary Transit Access interview locations.
• The fully completed original application along with proof of ID and address can be:
o Emailed to: calgarytransitaccesseligibility@calgary.ca
o Faxed to: 403-537-7812
o Mailed to:
Calgary Transit Access
Box 2100, Station M #WB170
Calgary, AB T2P 2M5
*Please complete all parts in black or blue ink only and keep a copy for yourself.
The personal information collected herein is authorized under Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act of Alberta, for the
purpose of facilitating transportation services through Calgary Transit Access and contracted transportation service providers. To ensure client safety, your name,
address and registration number will be disclosed to contracted service providers and supporting agencies to verify pick-up and drop-off. Should you have any
questions or concerns regarding the collection and use of your personal information, please contact Calgary Transit Access, at 403-537-7777, option 5, or feel
free to email us at calgarytransitsaccesseligibility@calgary.ca. ISC: Confidential
Registration # _____________________________
Calgary Transit Access Application
TS 5265 (R2018-04)
Part A - Personal Information
Are you a Calgary Transit Access Customer? No Yes If Yes, Registration #____________
First Name ______________________ Middle Initial_______ Last Name ______________________________
Date of Birth (YYYY/MM/DD) ________________________ Gender Male Female
Phone [H] (____)___________________ [W] (____)___________________ [C] (____)____________________
Street Address __________________________________________________________________Apt # ________
Calgary, AB
Postal Code_____________________ Email _______________________________________________________
Note: proof of address and Photo ID is required
If your residence has a name (i.e. Aspen Lodge) what is it? ______________________________________
Pick up door: Front Back Side Alley Garage Other ______________________
On arrival at your destinations, do you (the Applicant) need to be handed over to (met by) a staff
or family member?
I never need to be met by someone I always need to be met by someone*
*If you ‘always’ need to be met by someone, you are responsible to have that person meet you
when you arrive*
Can you be at home alone? Yes No*
*If ‘No’, you must provide a nearby address (other than your home address) where you can be dropped
off if there is no one at home to meet you.
2. Why are you applying for Calgary Transit Access shared ride service?
_________________________________________________________________________________________________
4. How does your disability prevent you from using Calgary Transit?
__________________________________________________________________________________________________
5. Is this a temporary disability or health condition? ________________________________________________
6. Do you have an upcoming scheduled surgery date? If yes, please provide date and type of
surgery. ______________________________________________________________________________________
7. If the weather is good, how many blocks can you wheel/walk before you need a rest?
1 Block 2 Blocks 3 Blocks 4 Blocks 5 Blocks
8. Can you learn to take regular Calgary Transit on your own? Yes No
If No, please explain why: _____________________________________________________________________
Have you been trained to use a Calgary Transit bus and/or CTrain? Yes No
If Yes, who provided the training? _________________________________________________________________
Part D - Transportation
1. How do you travel around Calgary now? (check all that apply).
Drive (self) Friends/family/staff drive Taxi
City Bus CTrain Calgary Transit Access – shared ride
Other (describe) ___________________________________
2. How often are you using a Calgary Transit bus or CTrain?
Daily Weekly Monthly Seasonally Occasionally Never
If “occasionally” or “never” tell us why._________________________________________________________
3. Your most recent trip on Calgary Transit (bus and/or CTrain) _________________ (month/year)
Was it a: Low-floor bus Bus with steps CTrain
4. How far is the closest bus stop to your home? ________________________________________________
What is the bus route number? ___________
5. If you are no longer using a Calgary Transit bus or CTrain when and why did you stop using it?
___________________________________________________________________________
6. List three of your most frequent destinations and how you get there.
7. If driven directly to a CTrain station, could this applicant get on the CTrain and travel to another
CTrain station to be picked up again?
Yes No If No please explain why not_____________________________________
8. Is there any additional information we need to know to provide transportation for the applicant?
Yes (see below) No
Speech impairment Non-verbal Hearing loss Vision loss
- May be aggressive (describe) _____________________________________________________
- Seizure disorder (type, frequency, recovery time) ______________________________________
- Behavioral/Risk to self or others (describe) ___________________________________________
_____________________________________________________________________________________________
(**Please note that compliance with the Calgary Transit Access Rules of Conduct as described in the
Calgary Transit Access User Guide is mandatory. The User Guide can be found at
www.calgarytransit.com and follow the Calgary Transit Access links.**)
If someone helped in completing this application, please provide the following information:
Name: ________________________________________Relationship to Applicant: __________________________
Email: __________________________________________________________________
Calgary Transit Access requires you (the Applicant) to be interviewed to determine eligibility.
**Please ensure you bring photo identification and proof of address to the interview.
To schedule an interview:
Who do we contact? You OR Someone else (If ‘someone else’ provide the following)
Name _________________________________________________ Daytime Phone # (_____)_______________
Relationship to Applicant ______________________________________________________________________
In order for Calgary Transit Access to evaluate your request for eligibility, it may be helpful for us to contact a
health professional (in addition to the health professional who is completing part G) who is familiar with your
condition. Please provide the name of a health care professional we can contact if we need more information.
**Please read then sign below to show you agree and give your consent. **
_______________________________________________________ _________________________________
Signature of Applicant (Legal Guardian if applicable) Date YYYY/MM/DD
Once your licensed health care professional has completed Part G, please mail, email or fax this form
together with all other sections and a copy of your photo identification and proof of address to Calgary
Transit Access at:
o Mail to:
Calgary Transit Access
Box 2100, Station M #WB170
Calgary, AB T2P 2M5
Eligibility is NOT based on age, income, language barriers, fear of crime, fear of using Calgary Transit, inability to
drive, unfamiliarity of how to use Calgary Transit or the length of a trip when using Calgary Transit.
To reduce confusion about what our service can offer, please do not complete these forms unless this applicant
cannot physically or cognitively use a bus or CTrain.
Please indicate what type of licensed health care professional you are:
I certify that I am currently an accredited / licensed practitioner, from one of the above
designations, and that the information on the following pages is accurate and complete.
7. Can the Applicant, with his/her mobility aid (if required), complete the following tasks:
Board a low-floor bus? Board a CTrain?
Walk/wheel to the closest bus stop? Step on/off a curb?
Ask the driver for assistance?
8. Is there a history of falls or a balance/gait concern? No Yes If Yes, please note the frequency and
cause: _________________________________________________________________________________________
9. If the applicant was driven directly to an CTrain station, could this applicant get on the CTrain and travel to
another CTrain station (to be picked up again)?
10. Describe if and how the Applicant’s day-to-day function is affected in the following areas:
Functional/Physical Health _____________________________________________________________________
Sensory _______________________________________________________________________________________
Cognitive _____________________________________________________________________________________
Mental Health __________________________________________________________________________________
Behavioral ____________________________________________________________________________________
11. Calgary Transit Access does not provide attendants. Does the Applicant require a mandatory attendant
for behavioral or medical reasons, to ensure the safety of self or others, when they are in a Calgary Transit
Access vehicle? (NOTE: Calgary Transit Access is a shared ride service for both children and adults).
No Yes If Yes, please explain __________________________________________________________
(*Please note that compliance with Calgary Transit Access Rules of Conduct as described in the Calgary
Transit User Guide is mandatory*)