Access 2 Entertainmenttm
Card
APPLICATION FORM
As
at: June 2007
SECTION A
The Access 2 EntertainmentTM card provides free admission
(or a significant discount) for support persons accompanying a person with a
disability at member movie theatres across Canada. The person with the disability pays regular admission. This program was developed by an
advisory group of nine national disability organizations, in conjunction with
Cineplex Entertainment.
Persons
with a permanent disability who require a support person when attending a movie
theatre are eligible for the card. The applicant must agree to follow the terms
and conditions for use of the card (see below).
A support
person is an individual who accompanies a person with a disability to provide
those services that are not provided by theatre employees, such as assisting
the person with eating, administering medication, communication and use of the
facilities.
We are pleased to have been able to
offer the first 20,000 cards free in the first year. From September 1, 2006 onwards there will be a $20 fee to acquire
the Access 2 Entertainment Card. The card will be valid for 5 years and will
include 2 free movie passes valued at approximately $20.00.
There are
two steps to apply for the card.
1. The
applicant must pay a $20 administrative fee to receive
·
an
Access 2 Entertainment card (valid for 5 years), and
·
2
free movie passes
valued at approximately $20
Note: A
cheque or money order for $20 can be made payable to Easter Seals Canada. We are unable to accept credit cards or
cash.
2. If the applicant has a CNIB client ID
card, or the Disability Travel CardTM
(issued by Easter Seals Canada),
· Complete Section B.
· Attach a photocopy of either the
CNIB client ID card, or the
Disability Travel Card. Do not send originals.
Note: With either of these cards, Section
C is not required.
OR
If the applicant does not have a
CNIB client ID card, or the
Disability Travel Card,
- Complete Section B.
- Have your health care provider
complete Section C, and attach to Section B.
·
The
application for the Access 2
Entertainment card must be verified by a Registered Health Care Provider as
defined in this application form.
Note: The applicant must be a
client/patient of the authorizing health care provider.
Terms
And Conditions:
1.
The
applicant must pay a $20 administrative fee to acquire the Access 2 Entertainment card.
2.
The
application form must be submitted by a person with a disability or a legal
guardian on his or her behalf.
3.
The
applicant must be identified as having a disability by a registered health care
provider or a recognized service provider and he/she must be a client/patient
of the authorizing health care professional/service provider.
4.
The
applicant must present the Access 2
Entertainment card along with personal identification at the movie theatre
Box Office when purchasing his or her own movie ticket.
5.
The
person with a disability and support person must attend the movie together.
6.
The
discounted admission fee for the support person will be free or no more than
$3.00. Prices may vary from theatre chain to chain.
7.
This
program is administrated by Easter Seals Canada on behalf of the Access 2 Entertainment Partners. Please allow 4 to 6 weeks for processing of
your application and delivery of your Access 2 Entertainment card. (Note:
If your $20 fee is not included in your application. Your application
will be held until the fee is received. This will increase the amount of time
it takes to process your application).
8.
This
card shall be valid for a period of 5 years from date of issue after which a
renewal application form must be filed with Easter Seals Canada with a renewal
fee TBA.
9.
There
is a $20 replacement fee for a lost or stolen card.
10.
Misuse
or abuse of this card shall result in the immediate termination and
confiscation of the card and its privileges.
11.
These
terms and conditions are subject to change without notice under the authority
of the Access 2 Entertainment Partners.
SECTION B: PERSONAL INFORMATION
PLEASE PRINT CLEARLY
Applicant’s Name:
______________________________________________________
Address:
_____________________________________________
Apt. #:___________
City: ________________ Province: __________ Postal
Code: ________________
Telephone: ( )____________________ Email: ____________________________
Do you have a:
q CNIB client ID card or
q Disability Travel Card (issued by
Easter Seals)
If yes, tick (ü) the appropriate box and attach a
copy of the card. Do not send originals.
If no, complete
Section B and have your health care provider fill out Section C.
PLEASE NOTE:
We are unable to
process your application without the $20 administration fee.
PRIVACY:
Easter
Seals Canada is committed to protecting
the privacy, confidentiality, accuracy, and security of any personal
information that we collect, use, retain, and disclose in the course of the
services we offer.
I hereby certify that I have read and understood all
the terms and conditions as set forth in the application for the Access 2 Entertainment card.
Applicant’s signature: ________________________ Date:
_____________
SECTION C: HEALTH CARE PROVIDER
INFORMATION
PLEASE PRINT CLEARLY
Name of Applicant:
______________________________________________________
Name of Authorized Health Care
Provider:
______________________________________________________________________
Registration Number (if applicable):
_________________________________________
Address:
______________________________________________________________
City: __________________ Province:
__________ Postal Code:
__________
Telephone: ( )_______________________ Email: _________________________
Please indicate (ü) the category of Authorized Health
Care Provider:
Physician q
Nurse (RN or RNA) q
Social Worker q
Occupational Therapist q
Physiotherapist q
Pharmacist q
Rehabilitation Counsellor q
Audiologist q
Recreational Therapist q
Kinesiologist q
Psychologist q
Other (explain):
______________________________________________________
PRIVACY:
Easter Seals Canada is committed to protecting the privacy, confidentiality, accuracy, and
security of any personal information that we collect, use, retain, and disclose
in the course of the services we offer.
I hereby certify that the applicant is a person with a
disability in accordance with the provisions of the Access 2 Entertainment card application and this
applicant is a client/patient of mine.
Health Care Provider’s
Signature: __________________________ Date: ______________________
SECTION D: ACCESS 2 ENTERTAINMENTTM
CARD PARTNERS
Participating Theatre Chains
Include:
Cineplex
Odeon Cinemas
Galaxy
Cinemas
Famous
Players Cinemas
SilverCity Cinemas
www.cineplex.com
Colossus Cinemas
www.cineplex.com
Coliseum Cinemas
www.cineplex.com
Empire
Theatres
Landmark
Cinemas
Rainbow
Cinemas
Magic
Lantern Cinemas
AMC
Theatres
Capital
Theatres (Yellowknife)
Theatre
Near You (Burnaby, Surrey, New Westminster BC)
… and other
Members of the Motion Picture Theatres Associations of Canada. Check with your
local theatre to confirm participation in this program.
National Advisory Group of
Disability Organizations
Canadian Abilities Foundation
Tel: (416)
923-1885
Web: www.abilities.ca
Canadian Association of the Deaf
Tel: (613)
565-2882
TTY: (613)
565-8882
Web: www.cad.ca
Canadian Association of Independent Living
Tel: (613)
563-2581
TTY: (613)
563-4215
Web: www.cailc.ca
Canadian Hard of Hearing Association
Tel: (613)
526-1584
Toll Free:
(800) 263-8068
Web: www.chha.ca
Canadian
Paraplegic Association
Tel: (613)
723-1033
Easter Seals Canada
Tel: (416)
932-8382
Web: www.easterseals.ca
Multiple Sclerosis Society of Canada
Tel: (416)
922-6065
Toll Free:
(800) 268-7582
Web: www.mssociety.ca
Alliance for Equality of Blind Canadians
Tel: (800)
561-4774
Web: http://www.blindcanadians.ca
People First Of Canada
Tel: (204)
784-7362
Toll free:
(866) 854-8915
Web: www.peoplefirstofcanada.ca
This program is
administrated by Easter Seals Canada.
Before submitting your application, see Application Form Checklist.
Please mail your application form, a cheque or money order to Easter
Seals Canada for $20 and a self-addressed, stamped, business-sized envelope to:
Access 2 Entertainment
C/O Easter Seals Canada
90 Eglinton Avenue East, Suite 208
Toronto, Ontario
M4P 2Y3
Please allow 4 to 6 weeks for
processing of your application and delivery of your
Access 2 Entertainment card.
For more information and regular updates, please visit our
website at www.access2.ca
Additional application forms are available from all members
of the
Access 2
Entertainment Card Partnership.
To locate accessible
resources and access to entertainment partners in your community, please visit
Access Guide Canada at www.abilities.ca/agc.
Access 2 EntertainmentTM is a trademark of Easter SealsTM
Canada.
Access
2 Entertainment Card
APPLICATION FORM
CHECKLIST
q Has Section B been completed by, or
on behalf of, a person with a disability?
q If the applicant has a CNIB client
ID card, or the Disability Travel
Card (issued by Easter Seals), did you include a PHOTOCOPY of the client ID
card? (Do not send original cards.), OR
q If the applicant does not have a CNIB ID card or the
Disability Travel Card, is Section C signed and dated by a health or service
provider (NOT a family member)?
q Are you sending Section B and
Section C of the application form only?
(It is not necessary to return the entire application form).
q Have you enclosed a cheque or money
order for $20 made payable to Easter Seals Canada?
q Have you enclosed a self-addressed,
stamped, business-size envelope?