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PAL Card Application

Please complete the following information. All information pertaining to this application is confidential.

Applicant's Age

Under 18

18 and Over

Name of PAL Card Applicant:

Date of Birth

Street Address:

City:

Province:

Postal Code:

Phone #:

Email:

Please provide a photograph (head shot):

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Allowed extensions jpg, jpeg, gif, png, tif

If you are unable to attach a photograph, we will be in touch with you to make arrangements to take a photo, should your application be successful.

If form completed by someone other than applicant, please provide:

Name:

Agency if applicable:

Contact Phone #:

Contact Email:

I request a Braille label on my Card

Yes

To determine eligibility requirements, please answer the following questions:

Is the disability:

Permanent

Temporary

Can your disability be corrected with the use of an assistive device? (eg. Eyeglasses):

Yes

No medical certificate or letter required for PAL Card eligibility. Please fill in the references sections.
The references must be people who know that the applicant meets the criteria: for example, agency or service provider, occupational or physiotherapist, teacher, etc. All references will be contacted by staff before the PAL Card application is approved. Please do not include friends or relatives as references.

Reference 1

Reference 1 Name :

Reference 1 Occupation:

Reference 1 Email:

Reference 1 Phone number:

Reference 2

Reference 2 Name:

Reference 2 Occupation:

Reference 2 Email:

Reference 2 Phone number:

The statements made above are, to the best of my knowledge, complete and accurate. By submitting this form I understand that a staff person will contact the references and that approval of this application depends upon verification that the applicant is a person with a disability who requires a support person to participate in or perform recreation/leisure activities.

Definition of Disability according to Statistics Canada

Disability:
Activity limitations experienced by individuals as a result of physical or mental conditions or health problems; the impact these limitations have on day-to-day life; help used or needed as a result of limitations, including specialized equipment and aids.

Personal information on this form is collected under the authority of the Municipal Act, R.S.O. 1980,c.302 (as amended) and will be used within the programme for emergency contact and program follow-up. Questions regarding this collection should be directed to the Supervisor Aquatics, Wellness, Children and Youth 420 Winnipeg Ave, Thunder Bay, ON P7B 6B7.