Please note that fields indicated with a * are requires fields.

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* 1. Who is this application for?

I am applying for myself

I am applying on behalf of someone else

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* 2. ELIGIBILITY CRITERIA

Aged 12 or older.

Have at least one of these conditions:
- Autism spectrum disorder (ASD)
- Mild intellectual disability (MID)
- Developmental language disorder (dysphasia)

Have a relationship with at least one of the following organizations:
- CISSS de Laval
- Regroupement des organismes de promotion de personnes handicapées de Laval (ROPPHL)
- Autisme Laval
- Centre de service scolaire de Laval (CSSL)
- Sir Wilfrid Laurier School Board (SWLSB)

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* 3. Please specify which organization(s):

CISSS de Laval

Regroupement des organismes de promotion de personnes handicapées de Laval (ROPPHL)

Autisme Laval

Centre de service scolaire de Laval (CSSL)

Commission scolaire Sir-Wilfrid-Laurier (SWLSB)

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* 4. Avoir l'ensemble des capacités suivantes:

- Walk on the sidewalk
- Recognize bus stops
- Differentiate between moving cars and parked cars
- Cross the street safely (crosswalks, green light, being vigilant, etc.)
- Commute in bad weather
- Stay standing if there are no free seats on the bus
- Able and open to learning how to use a smart phone
- Able to express yourself and have relatively good hearing

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* 5. PERSON REGISTERING TO USE STL COMPAGNON

Prénom *

Nom *

Email *

Téléphone *

Other phone

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* 6. CONTACT PERSON/GUARDIAN

Contact person’s first name

Contact person’s last name

Contact person’s email

Contact person’s phone number