Required fields are marked with asterisks (*)

Support Worker Pass Application

Support Worker refers to any individual designated to providing assistance to a person with a disability, allowing them to participate in programs where they would otherwise be unable.

Information for person needing support

Full name of the Person with a Disability

Date of birth

Address

City or Town

Province

Postal Code

Phone Number (Main)

E-mail Address

The person listed above requires support?

Yes

The medical condition of the person requiring support is permanent?

Yes

Information of person completing the form

This section is to be completed by the person submitting the form.

Full name

Date of birth

Phone number