Fillable TEMPORARY EXEMPTION REQUEST FOR PASSENGERS DUE TO ESSENTIAL

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TEMPORARY EXEMPTION REQUEST FOR PASSENGERS DUE TO ESSENTIAL

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TEMPORARY EXEMPTION REQUEST
FOR PASSENGERS DUE TO ESSENTIAL
MEDICAL SERVICES OR TREATMENT
A. INSTRUCTIONS FOR PASSENGERS
The person requesting a temporary exemption must submit a completed copy of this form in its entirety to the
Air Canada medical assistance desk at acmedical@aircanada.ca. All pages must be reviewed and completed
by the person to be exempted and/or the requester, as well as by the required Canadian medical doctor or
nurse practitioner.
This exemption form must be completed no later than 14 days prior to time of departure and for each One return
trip within Canada, or one one-way trip from Canada. Passengers may also be asked to provide the completed
exemption form any time Proof of Vaccination is required (e.g. at time of booking, at check-in, before boarding,
etc.) and must retain it with them at all times. Air Canada will approve or deny exemptions requests on the basis
of Government of Canada guidance.
In accordance with Transport Canada regulations, passengers who are approved with a temporary exemption will
need to present to Air Canada at time of boarding results of a COVID-19 molecular test taken (PCR, NAT, NAAT,
LAMP) prior to boarding (Antigen Test are not accepted):
•
Within 72 hours of the passenger’s scheduled departure time, where the result is negative, or
•
At least 14 days before but not more than 180 days prior to the traveler’s scheduled departure time
(traveler eligible to travel on day 15), where the result is positive.
At least 14 days before but not more than 180 days prior to the traveler’s scheduled departure time(traveler eligible to travel on day 15), where the result is positive.
B. PASSENGER TO BE EXEMPTED
Please provide the following concerning the passenger for which a temporary exemption is requested,
using the exact name as stated on the booking:
FIRST NAME LAST NAME
ADDRESS UNIT OR APARTMENT
TOWN OR CITY PROVINCE POSTAL CODE
COUNTRY OR REGION EMAIL TELEPHONE
Has a previous temporary exemptions request been made for this person?
If yes, please provide details:
DATE NAME OF CARRIER OR OPERATOR
Was the temporary exemption approved?
ACF5029-EN-UA - RDIMS #18081032 (2021-12 v1)
2
C. REQUESTER’S INFORMATION
If the requester is different than the passenger to be exempted, please complete the following:
FIRST NAME LAST NAME
ADDRESS UNIT OR APARTMENT
TOWN OR CITY PROVINCE POSTAL CODE
COUNTRY OR REGION
EMAIL TELEPHONE
D. TRAVEL INFORMATION
Please provide the following travel details for the Passenger for which a temporary exemption is
requested: (Note: this form is valid for one one-way from Canada or round trip within Canada only,
based on the flights booked on a single booking reference (PNR).
BOOKING REFERENCE (PNR):
FLIGHT NUMBER DATE FROM TO
FLIGHT NUMBER DATE FROM TO
FLIGHT NUMBER DATE FROM TO
FLIGHT NUMBER DATE FROM TO
E. CONFIRMATION BY CANADIAN MEDICAL DOCTOR OR NURSE PRACTITIONER
I,
_________________________________
(full name of Canadian medical doctor or nurse practitioner),
hereby confirm that the person to be exempted above is travelling for the purpose of obtaining essential medical
services or treatment. I have also completed and attached the Air Canada Fitness for Travel Form.
https://www.aircanada.com/content/dam/aircanada/portal/documents/PDF/en/fft.pdf
DATE(S) OF APPOINTMENT FOR WHICH TRAVEL IS REQUIRED:
NAME OF MEDICAL FACILITY CIVIC ADDRESS OF MEDICAL FACILITY
Does this Passenger require an escort or companion traveller?
FIRST NAME OF ESCORT OR COMPANION
TRAVELLER :
LAST NAME O F ESCORT OR COMPANION
TRAVELLER :
Please note – escort or companion may be required to be fully vaccinated or have been approved
for own vaccination exemption unless meeting the following criteria:
A competent person who is at least 18 years old and who is boarding an aircraft for a flight for the purpose of
accompanying a person if the person needs to be accompanied because they:
• are under the age of 18 years,
• have a disability, or
• need assistance to communicate;
The escort will also require a proof of negative PCR or molecular test within 72 hours from time of travel.
SIGNATURE FULL NAME
DATE ADDRESS
TOWN/CITY PROVINCE POSTAL CODE
EMAIL TELEPHONE
CANADIAN OR PROVINCIAL OR TERRITORIAL CERTIFICATE OR
LICENSE NUMBER:
3
REQUESTER’S ATTESTATION
The following is to be completed by or on behalf of the passenger requesting a temporary exemption:
I hereby certify that I am / or the person for which a request is made to travel for the purposes of obtaining
essential medical services or treatment:
SIGNATURE FULL NAME
DATE EMAIL TELEPHONE
F. ACKNOWLEDGEMENT – FALSE OR MISLEADING INFORMATION
I acknowledge that it is an offence under section 366 of the Criminal Code to make a false document, knowing it to
be false.
As per the applicable Transport Canada Order, a person who provides information to a carrier/operator that
is
known
to be false or misleading may also be subject to an administrative monetary penalty or other
enforcement action,
including
prosecution.
G. PERSONAL INFORMATION
Your privacy is important. Personal information you provide in this form will be used for the purposes of determining
the qualification of the person identified on this form for temporary exemption from the requirements of the applicable
Transport Canada Order. Please note that Air Canada is subject to applicable privacy legislation with respect to the
handling of your personal information. The personal information in this form may be provided to and used by
Transport Canada for the purpose of audit and enforcement. The Minister of Transport may collect this personal
information pursuant to the applicable legislation, under the Aeronautics Act, Railway Safety Act or Canada Shipping
Act, 2001.
In the event that any personal information is provided to Transport Canada, it will only be used and disclosed by
Transport Canada in accordance with the Privacy Act and its regulations. The personal information collected, as
well as its use, disclosure and retention is described in the personal information bank numbered TC PPU 015, for
civil aviation, and other applicable personal information banks (“PIB”) for other modes of transportation, which are
currently being developed and/or modified, and will be published on Transport Canada’s Info Source page
(https://tc.canada.ca/en/info-source). In the interim, please visit the following website for more information:
COVID-19 information for travellers within Canada. Under the provisions of the Privacy Act, individuals have the
right of access to, correction of and protection of their personal information. Instructions for obtaining personal
information are provided in Info Source, a copy of which is available in major public and academic libraries or
online at http://www.infosource.gc.ca.
Individuals who wish to exercise their right to complaint under the Privacy Act about the handling of their personal
information may do so by filing a complaint with the Office of the Privacy Commissioner. For information on how
Air Canada processes your personal information, please visit our privacy policy.
H. EXEMPTION AUTHORITY STATEMENT
Please
note
that
any
exemption
granted
in
accordance
with
the
applicable
Transport
Canada
Order is
only for the
purposes of travel within or out of Canada. Any traveler
entering Canada by any mode is still
subject to all border
entry requirements including quarantine requirements imposed under the Quarantine
Act.
CLEAR FORM
4
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TEMPORARY EXEMPTION REQUEST FOR PASSENGERS DUE TO ESSENTIAL

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Completed 9 January 2022

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