Online Application - Client Application - Attendant Services Program

Basic Information

Full name of applicant*

First Last

Home address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone

This application is for*

Fall Term
Winter Term
Summer Term

I will be attending:*

Carleton
Algonquin

Do you require assistance with any of the following procedures:

cough assist
CPAP/BiPAP
secretion suctioning
high flow oxygen therapy

I am*

A new client
A returning client

General Information

Have you applied for academic admissions?*

Yes
No

Have you applied for residence accommodations?*

Yes
No

Intended duration of stay*

Academic year (September to April)
Year round

Do you currently receive, or do you anticipate receiving, any funding for attendant services?*

Yes
No

• If you are an Ontario resident, have you applied with the Ontario Student Assistance Program?

Yes
No, out of province
No

This form is not a contract; by selecting “Submit”, you are stating you understand all the information above and have inputted the required information.

Online Application – Client Application

Basic Information

General Information