VAN Go Request Form (Student Accessibility Services)

Welcome to York University's mobility services program! This program was jointly developed and designed by Student Accessibility Services and Transportation Services to enhance the transportation needs in and around York's Keele campus for persons with disabilities. Transportation is provided with a wheelchair accessible van.

If you have already registered with Student Accessibility Services, please contact your Accessibility Counsellor about access to VAN Go.

Before we begin, will you require academic accommodations in addition to transportation?

Before we begin, will you require academic accommodations in addition to transportation? I only require transportation services I would like to discuss academic accommodations Other Other
Demographic Information
Name Name * First Last
Pronoun(s):
Date of Birth Date of Birth * / MM / DD YYYY
York Student Number: *
Please provide us with your preferred email - one that you check regularly.

This email does not have to be your York email. However, please note that HOTMAIL accounts/messages often get flagged as junk mail and messages can be lost. *

We will contact you via this email address. If you've provided a "hotmail" address, please remember to check your junk mail.
Student's Cell Phone Student's Cell Phone * - ### - ### ####
Can we leave a message at this number?

Can we leave a message at this number? Yes No
Disability Related Documentation Upload
Upload an electronic copy of your medical documentation here as a "PDF" or "Word" document.

If you do not have a scanner/electronic copy of your documentation, you can use your phone to take pictures and convert them into a "PDF" or "Word" document with an APP like iScanner or CamScanner. Using "Adobe Acrobat" you can combine multiple files/documents.

Please email sasreg@yorku.ca with questions or concerns. *

Attach Files

All relevant disability related documentation should be uploaded to this form. To attach your documentation, select "Browse", find the document you would like to attach and double click.
Nature of Disability

Some students have more than one disability. Please check all those which might apply to you.
The nature of my disability is (see Ridership Criteria & Policies Below)

The nature of my disability is (see Ridership Criteria & Policies Below) Mobility Impairment Systemic Disability Visual Impairment Other - Please specify Other - Please specify

Students who are diagnosed with multiple disabilities should check all relevant boxes.
Ridership Criteria & Policies

The following criteria and policies have been created by Student Accessibility Services and Transportation Services to ensure an equitable and efficient program. If you have any questions or concerns about the following, please do not hesitate to contact us at sasreg.yorku.ca (preferable) or 416-736-5755.

Criteria:
a) All riders must register with Student Accessibility Services.
b) The York University Van Go program is designed to service numerous students who have either a temporary or permanent disability which affects one or more of the body's systems. A classification of some of these conditions include (but are not limited to):
i) Mobility Impairments: those individuals who utilize a technical aid for mobility or independent living. For example, those who use a cane, walker, crutches, wheelchair, electric wheelchair or scooter, would be eligible to utilize the program.
ii) Systemic Disabilities: those individuals whose mobility is limited due to a condition akin to one of the following; AIDS, cancer, chronic migraines, epilepsy/seizure disorder, fibromyalgia, multiple chemical sensitivity, traumatic brain injury, asthma or respirator disorders, would be eligible to utilize the program.
iii) Visual Impairments: Persons who are visually impaired will be eligible to utilize the program.
iv) Any other individual wishing to utlize the service due to a Mental Health or Learning Disability mus be referred to Student Accessibility Services.
Notification of How Your Information Will Be Used

Student Accessibility Services collects medical documentation and other information pertaining to your functional limitations, your history of learning or personal circumstances for the following purposes:

• To verify the need for disability related accommodations for academic work and
• To develop and implement effective disability related accommodations and supports

Student Accessibility Services respects your privacy and keeps your information confidential. Information may be shared with university staff, but only on a need-to-know basis to allow them to perform their duties and to provide academic or other disability related accommodations on campus.

Examples:

• Test and Exam accommodations will be shared with the Alternate Exam/Test Scheduling for invigilation.
• The name of students with a reduced course load as an accommodation may be shared for fees adjustment purposes or to arrange bursaries.
• Accessibility Counsellors may speak to a professor, registrar or residence staff to arrange accommodations and supports.
• When a student encounters difficulties that require attention from other University units, such as Student Counselling & Development, Students of Concern Committee, Office of Student Community Relations, Residence Life, necessary information is shared with those units.

To protect your information, all university staff receiving information follows University policies and guidelines, the Freedom of Information and Protection of Privacy Act and other legal requirements*.

Frequently Asked Questions (FAQs) About How Information is Used is available from the
page of our website:

If you have any questions, please send an email to sasreg@yorku.ca.

Your email will be forwarded to the Director for follow up as soon as possible.

* Student Accessibility Services provides academic accommodation and support to students with disabilities in accordance with the Ontario Human Rights Commission’s Policy on accessible education for students with disabilities and York University Senate Policy on Academic Accommodation for Students with Disabilities.

Student Accessibility Services at York University is subject to the Freedom of Information and Protection of Privacy Act ("FIPPA") and York University’s Policy on Access to Information and Protection of Privacy. Information is collected under the authority of The York University Act, 1965 to administer the university-student relationship.
• By signing this form, you acknowledge that you have read and understand the "Notification of How Your Information Will Be Used". *
By signing this form, you acknowledge that you have read the "Notification of How Your Information Will Be Used" *

Clear
Date Completed: Date Completed: / MM / DD YYYY

VAN Go Request Form (Student Accessibility Services)

VAN Go Request Form (Student Accessibility Services)

Demographic Information

Disability Related Documentation Upload

Nature of Disability Some students have more than one disability. Please check all those which might apply to you.

Ridership Criteria & Policies

Notification of How Your Information Will Be Used

Nature of Disability

Some students have more than one disability. Please check all those which might apply to you.