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Personal Attendant for Leisure (PAL Card) Application

Please complete the following information. All information collected on this application is confidential.

First & Last Name

Address (including Postal Code)

Phone Number

Date of Birth

Gender

Male

Female

Other

Please answer the following questions to determine eligibility.

1. Is the disability permanent or temporary?

Permanent

Temporary

2. Has the disability lasted longer than 6 months?

Yes

3. Is the disability eliminated by the use of a technical aide (e.g. eyeglasses)?

Yes

At present,this program does not require a medical certificate for PAL Card eligibility. However, it is necessary to have verification that the applicant has a disability, therefore references are required.

The references must be people who know the applicant meets the criteria for example Occupational Therapist or physiotherapist. All references will be contacted by Township staff before approval.

Reference 1

Reference 2

Please sign and date

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