Rider Application

Please complete the online application form below. If you prefer, you may also download and complete the printable PDF version of the Rider Application Form and submit it by email to info@drivehappiness.ca or by mail to the Drive Happiness office.

Items with * are required.

Mailing Address (if different from above)

Complex name and buzzer number

Spouse's Name (A seperate application is needed)

English Proficiency

Fluent Functional

INCOME: Annual Gross Income (Line 15000 of Tax Return):

Household Information

Do you live alone?

Yes No

If no, who lives with you?

Building Type

House Apartment Seniors-only building

Transportation Information

DATS membership (Edmonton only):

Yes No

Disability Placard:

Yes No

Still driving?:

Yes No Seasonally

Mobility Information

Do you use any mobility aids (i.e. cane or walker)?:

Names of your attendants or persons accompanying you (if applicable):

Can you get in and out of a vehicle with minimal assistance?

Yes No

Emergency Contact

Emergency Contact Name

Emergency Contact Number

Emergency Contact Email

Relationship with Emergency Contact

Health Information / Barriers
Please check all conditions that affect your mobility, health, and safety

MOTOR FUNCTIONS

If "Other", please specify:

COGNITIVE FUNCTIONS

If "Other", please specify:

MAJOR HEALTH

Cancer Dialysis Other

If "Other", please specify:

MENTAL HEALTH

Anxiety Depression Other

If "Other", please specify:

Do you receive homecare services?

Yes No

Other Barriers

Vision barrier Legally blind Hearing barrier

Is there anything else we should know?

How Did You Hear About Us?

If "Other", please specify:

Rider Application Agreement

By checking this box you agree that the information you provided is true; that you allow your information to be shared between Drive Happiness partners and your emergency contact; that Drive Happiness has your permission to contact your emergency contact; that you consent to receiving communications related to Drive Happiness partners; and that you will not take legal action against Drive Happiness or their volunteers. Upon acceptance into the rider program, you will automatically become a member of Drive Happiness Seniors Association with all the rights and privileges of membership; including attending and voting at our Annual General Meeting.

Charitable #: BN 86424-1310 RR0001

We are located on Treaty 6 / Métis Territory.

Rider Application

We've receieved your submission and will get back to you soon

Questions in the meantime?