VATL - Vignette d'accompagnement touristique et de loisir

Identification

Name

First name

Gender

Male

Female

Address
(street an apartment)

Town

Postal Code

Country

Province

Administrative region

Phone

Email

Sticker number

Date of birth

Information concerning the autonomy of the applicant

Principal diagnosis

OTHER: Specify (ex: Asperger, macular degeneration, dysphasia, hearing impaired, multiple sclerosis, Tourette's syndrome, trisomy 21, etc.):

Secondary diagnosis

Yes

No

If yes, specify

Communication

Does the applicant have problems communicating?

Yes

No

If yes, answer the following questions, if not go to the nutrition section.

Does the applicant use a language (optionnal)

Verbal

Non-verbal

N/A

Does the applicant use a communication devise, specify (optionnal)

Is the applicant(understood)

Easily

With difficulties

N/A

Specify (optionnal)

Does the applicant(understand)

Easily

With difficulties

N/A

Specify (optionnal)

Nutrition

Is the applicant able to independently:

Eat

Yes

No

Transport lunch tray

Yes

No

Cut their food

Yes

No

Make safe food choices (ex: allergies, medication, diet, etc.)

Yes

No

Specify the level of help needed:

Personal care

Is the applicant able to be autonomous for:

Personal hygiene

Yes

No

Getting dressed

Yes

No

Take medication

Yes

No

Use the bathroom

Yes

No

Specify the level of help needed:

Interpersonal relationship

Is the applicant able to be autonomous for:

Respect and follow the rules

Yes

No

Connect with others appropriately

Yes

No

Exercise good judgement

Yes

No

Does the applicant need coaching for behavioural problems such as : Impulsiveness, opposition, verbal or physical aggressiveness

Yes

No

Specify (optionnal):

Transports and transferring

How does the applicant get around?

Walk freely

Yes

No

Walking with technical aids

Yes

No

If needed, specify
(ex: cane, wheelchair, guide dog or service dog, etc.)

Is the applicant able to move around independently on:

A flat surface

Yes

No

A rough surface

Yes

No

A short distance

Yes

No

A long distance

Yes

No

Is the applicant able to orient him or herself in a:

Familiar location

Yes

No

Unfamiliar location

Yes

No

Does the applicant use autonomously:

Public transportation

Yes

No

Adapted transportation

Yes

No

Autre

Specify any other needs that require the presence of a companion
(ex: keeping track of time or money etc.)

Is this person member of an association for the handicapped ?

Yes

No

Si OUI, laquelle ?

Enter the name and phone number of a contact person with the name of their organization or institution (organization for people with disabilities, rehabilitation center, CLSC, etc.).
Mandatory information, otherwise the application will be rejected.

By what means did you become aware of the existence of this program?

Get the Companion Sticker

Application for the companion sticker

Application type

Identification

Information concerning the autonomy of the applicant

Communication

Nutrition

Is the applicant able to independently:

Personal care

Is the applicant able to be autonomous for:

Interpersonal relationship

Is the applicant able to be autonomous for:

Transports and transferring

How does the applicant get around?

Is the applicant able to move around independently on:

Is the applicant able to orient him or herself in a:

Does the applicant use autonomously:

Autre