Register

Kingston Access Bus (KAB) Registration Online

Please complete this form

It will help speed the processing of your application if you follow these instructions carefully. If further assistance is required to complete this form, please telephone 613-542- 2512.

ELIGIBILITY CRITERIA:
1. Kingston Access Bus is a service for individuals with physical disabilities regardless of age who, due to a mobility impairment, are unable to use conventional transit facilities.
2. Individuals who are elderly, blind, or who have emotional problems, epilepsy, and/or mental disabilities may be eligible for our service ONLY IF, in addition to the above, they have a PHYSICAL DISABILITY which prevents them from using a public transit vehicle.
COMPLETION OF APPLICATION FORM:
1. Fill out all parts of the form below including the physician's referral, if you would prefer, print a copy for mailing.
2. If you do NOT use a wheelchair, you will be required to have a mobility assessment.
3. All persons require a referral by their physician. (see part 2 of online form)

PHYSICIAN'S REFERRAL FOR MOBILITY ASSESSMENT (Click here for page):

Print form. (This form must be printed and filled out by your physician. You do so by either printing the page or printing the pdf attached).

Fill out all parts of the form which apply to you.

Bring in or fax to Kingston Access Bus at 613-549-6318

Name

Title:

First Name:

Last Name:

Address

Address: Apt:

City:

Province: ONTARIO Postal Code:

Residence Name
(if appropriate):

Home Phone:

Alternate Phone: Ext.

E-mail:

Is your disability: Permanent Temporary

If temporary, approximately how long?
(Individuals with temporary disabilities may require reassessment)

Do you use a wheelchair? Yes No

If yes, is it: Standard Electric

If you use a wheelchair, is your residence ramped? Yes No

If no, state accessibility:

if you do not use a wheelchair, do you walk with an assistive device?
Yes No

If yes, please specify the type used:

Do you travel with a companion? Yes No

Name of person to contact in an emergency?

Name:

Phone No: Ext:

I HEREBY AUTHORIZE THE KINGSTON ACCESS BUS TO DETERMINE MY ELIGIBILITY AND IF DEEMED NECESSARY, TO CONSULT MY PERSONAL PHYSICIAN.

Can this passenger travel on their own without an assistant or aide?
Yes No

If "NO" please give a brief explanation:

Can this passenger be safely left alone at their drop-off location without being placed in the care of another person?
Yes No

If "NO" please give an explanation:

If the answer to question 2 is NO, please provide names, addresses and phone numbers of 2 other responsible persons who will receive this passenger in the event that no one is available at the home or the drop-off location.

First Choice

Name:

Address:

Phone: Ext:

Second Choice

Name:

Address:

Phone: Ext:

Please add any other comments or information that you feel will be helpful.