U-Pass BC Program Medical Exemption Form PROGRAM INFORMATION U-Pass BC is a mandatory program that provides Langara College students with unlimited access to TransLink services in Metro Vancouver. Langara’s agreement with TransLink allows for students to be ineligible or exempted in very specific and limited situations. This includes: • students registered in less than three credits, • students who hold a valid transit pass (not including monthly pass) or U-Pass BC from another post-secondary institution for the semester, • students who are permanently or temporarily disabled and whose physical or cognitive barriers cannot be accommodated by using the U-Pass BC benefits, and • students who do not reside in and do not attend on-campus classes in Metro Vancouver. If you have any questions about your eligibility, please email [email protected]. STUDENT INFORMATION Student name: Langara ID: Email: Phone: MEDICAL ASSESSMENT (to be completed by a qualified medical assessor) Do you feel that the nature of this student’s medical condition prevents them from using public transit? Yes No How long will this student’s condition prevent them from using public transit? (This question will determine the validity of this document for exemption from future semesters) Less than four (4) months Four (4) - Eight (8) months Eight (8) - Twelve (12) months Indefinitely Notes: Doctor’s signature: Date (YYYY/MM/DD): Name of certifying medical assessor: Registration/Certificate number: Please continue form on second page. Page 1 of 2 U-Pass BC Program Medical Exemption Form continued MEDICAL ASSESSMENT (to be completed by a qualified medical assessor) continued MEDICAL OFFICE STAMP *REQUIRED FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY Langara College collects the information on this form under the authority of the College and Institute Act [RSBC 1996, Chapter 52, Section 41.1] and the Universal Transit Pass Agreement (U-Pass BC), and in compliance with the Freedom of Information and Protection of Privacy Act [RSBC 1996, Chapter 165]. This information relates directly to the College’s administration of the U-Pass BC Program and is needed and will be used to make a decision regarding your application for exemption from the U-Pass BC Program. For questions about the collection, use and disclosure of your personal information, contact Registrar & Enrolment Services at 604.323.5241. Page 2 of 2.