Saugeen Mobility

and Regional Transit

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Client Registration Form

Client Information and Location

Please fill in as much information as possible to help us serve you better. There are a number of fields that are required. Thank-you.



Client Name

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Residential Facility (if any)

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Street Address

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Town/Village

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Postal Code

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Phone Number

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Cell Number

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Email Address

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Billing Information

NOTE: If this is the same as the client information you may proceed to the "Next Page".



Client Name

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Billing Street Address

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Billing Town/Village

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Billing Postal Code

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Phone Number

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Cell Number

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Emergency Contacts

For your safety, please supply us with some emergency contact information. We will only use this for emergency purposes. Thank you.



Emergency Contact

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Contact Phone Number

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Contact Cell Number

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Emergency Contact

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Contact Phone Number

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Contact Cell Number

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Attendant Information

An attendant (family member, personal support worker, care facility worker etc.) must be present to assist clients as needed onto and off of the vehicle.
An attendant may be required. Please inquire.
Attendants may travel with clients at no additional charge




Wheel Chairs and Other Equipment

Please indicate what type of wheelchair you are using and what other equipment you are using to assist with your mobility. Select as many as are applicable.


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Other Equipment not listed above


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Medical Conditions and Other Information

Please indicate any medical conditions or other information you feel our staff should know about.


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Confidentiality

Please be assured that all the information collected on this form will be kept strictly confidential and will not be released without your permission!

Name of Person Filling out this form.

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Date

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