BOOKING ELIGIBILITY APPLICATION

BOOKING ELIGIBILITY APPLICATION FORM

Eligibility Number For office use only

Cold Water Ranch Lodge

BOOKING ELIGIBILITY APPLICATION

Name of applicant *

Date *

Name of person acting for applicant(if applicable)

>> Relationship of this person to applicant:

Date Of Birth of the applicant *

Address *

City *

Province *

Postal Code *

Phone *

Cell

Contact email

Abilitas Foundation collects medical information relating to applicants to determine if the lodge is equipped in a manner that is suitable for the applicant and in order to determine whether other guests with differing disabilities could reasonably stay at the lodge at the same time as the applicant. All medical information is held in strict confidence by Abilitas Foundation but sometimes we may share a limited amount of information with other guests who attend the lodge to ensure bookings are compatible. We will contact you before we disclose any information to another guest to discuss our disclosure with you.

QUESTIONS FOR APPLICANT

1)Explain the diagnosis of your condition:

2) How does this condition limit you in the functions of daily living?(i.e. eating, dressing, feeding, personal care)

3) What equipment/ level of access do you need in a facility to accommodate your needs?(i.e. lifts, commode, hospital bed)

4) How do commercial accommodations (hotels etc.)fail to meet your needs?

5) Is this condition permanent? Yes No

6) What, if any, Long Term Income Supplement do you receive? (BC or CPP Disability Pension, Child Child Tax Credit, Autism Funding)

Additional Information (if any)

Please bear in mind that it is the intention of Abilitas Foundation to provide overnight accommodation at the Cold Water Ranch Lodge to people with severe disabilities. For questions, call Arlene Schouten at (604) 556-0681 or Meredith Holmes at (604) 854-1720.

POLICIES AND GUIDELINES:

Upon arrival, if the nature of the applicant's disability is not consistent with the information provided on the booking eligibility application, Abilitas Foundation reserves the right to review and revoke booking privileges.
Whether a child is restricted in any of the activities of daily living will depend on the child's age and expected development. The age is relevant, since a two-year-old child (e.g.) would not be expected to dress without assistance.

POD 1

POD 2

POD 3

POD 4

BOOKING ELIGIBILITY APPLICATION