Application form page

A. Applicant information - To be completed by all

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First name *

Last name *

Address (Number, street) *

Apartment

City *

Province *

Postal code *

Region *

Home phone *

Office phone

Cell phone

Gender *

Female
Male
Other

Email address *

Date of birth (YYYY-MM-DD) *

Language of correspondance *

English
French

Reason for the need for support : *

See the section on support needs for more information. Please check the one or more that apply to you

If applicable, indicate any other relevant information concerning your support needs:

Photo *

Make sure you meet the criteria for the photo.

B. Contact details of the applicant’s representative (if applicable)

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First name

Last name

Home phone

Work phone

Cell phone

Email address

Details (other)

Name of your organization (center, institution, organization)

C. Undertaking and signature of the person requesting the card - To be completed by all

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If I obtain the Companion leisure Card, I undertake to:

present the card to partner organizations that recognize it;
choose a person who is able to act as an accompanying party and meet my needs for a safe and proper conduct of the activity;
inform the AQLPH of any change in coordinates, or if ma card is lost, stolen or broken;
comply with the prohibition to lend the card to another person.

Signature *

I certify that the information I have provided to determine my eligibility for the card is accurate.

Proof of eligibility

Please check the statement that applies *

I have proof of eligibility
attach it in a PDF format
I do not have proof of eligibility
fill in the section
D. Authorization to disclose personal information for verification with a worker in the health and social services network
and attach a scanned file of the section
E. Certification by a health or social services worker
Téléchargez la partie E du formulaire ici.

File for your proof of eligibility *

D. Authorization to disclose personal information for verification with a worker in the health and social services network - To be completed if you do not have proof of eligibility

Worker's first name *

Worker's last name *

Applicant's first name *

Applicant's last name *

Date of birth (YYYY-MM-DD) *

Signature *

I authorize the health worker, whose name appears above, to confirm the information provided in section A for the sole purpose of accessing the CAL.

Date (YYYY-MM-DD) *

E. Certification by a health or social services worker - To be completed if you do not have proof of eligibility

Scanned file of Section E *

E. Government programs and measures recognized for eligibility purposes

You will obtain the Accompagnement loisir card if:

you are a recipient of one of the following government programs and measures;
and that you are able to provide evidence to support it.

Please check the statement that applies *

Special Needs Allowance Program for study (Adult) - Accompaniment services provided
If you have any support provided as part of vocational training, adult education, college, university, please attach the calculation statement, taking care to censor all personal information, except your name and the form of support received.
Supplement for a handicapped child (Retirement Québec)
If the supplement for a disabled child is granted to your child, please attach the letter from Retraite Québec confirming this.
Canada child benefit (Canada Revenue Agency)
If the Canada child benefit is granted to your child, please attach the letter confirming this.
Amount for severe and prolonged impairment in mental or physical functions (Revenu Québec)
If you are eligible for the tax credit for severe and prolonged impairment in mental or physical functions, please attach the notice of assessment demonstrating your eligibility (line 376), censoring all other information except your name, date of birth and home address.
Disability amount (Canada Revenue Agency)
If you are eligible for the disability tax credit, please attach the Canada Revenue Agency’s notice of determination confirming it.

Supporting document *

PDF format required.

F. Accompanying card recognized for eligibility purposes

You will obtain the Accompagnement loisir card if:

you already hold one of the following accompanying cards that required a professional assessment of your support needs;
and are able to attach a photocopy.

Please check the statement that applies *

The Quebec accompaniment card for intercity coach transportation (Fédération des transporteurs par autobus)
The STM accompanying card (Société de transport de Montréal)
CNIB identification Card

Supporting document *

PDF format required.

Optional section

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This section of the form is optional. This information will remain confidential and used only for a better understanding of user profiles by diagnosis, in order to provide you with better services.

Main disability (other)

I. Protection of personal information

The personal information collected is necessary to study your request. Only relevant staff within the AQLPH can access it.

This card is issued by the Association québécoise pour le loisir des personnes handicapées (AQLPH), with the support of the regional authorities responsible for the recreation of persons with disabilities and the financial participation of the Government of Quebec.

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La carte violette et la carte bleue sont acceptées.