HOW TO REGISTER FOR THE BACK ON TRACK PROGRAM. NOT your search engine. Registering online may save you 2 weeks in mailing time

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1 1 ONLINE Registration package TIPS HOW TO REGISTER FOR THE BACK ON TRACK PROGRAM ` Register Type into your address box NOT your search engine Within 72 business hours you will receive: Registration Confirmation The phone numbers to our locations across Ontario You will need your: Your Driver s Licence Number Your Credit Card # and Expiry Date Save Time NEW: Aug 3, 2010 Are you eligible for Reduced \ Suspension? Register NOW! Please allow up to 60 days to: Register for Back on Track Schedule an Assessment Complete an Assessment* *This can take up to 30 days from the day you book your appointment You may only have 90 days to meet this requirement Check your Notice of Suspension for your specific requirements! Registering online may save you 2 weeks in mailing time Visit to register today. Type into your address box NOT your search engine

2 2 REGISTRATION Using money order / Certified Cheque Instead of Registering online at use these forms and include: STEP 1: The signed Registration copy of the participant agreement STEP 2: The completed Back on Track registration form STEP 3: Include a certified cheque or money order for $578 payable to Back on Track Remedial Measures Program Step 1. Sign the Participant Agreement. The agreement explains what you need to do to successfully complete the Back on Track program and the consequences if you do not. It also tells you how personal information about you will be handled by program staff. Take the time to read the Participant Agreement carefully. Two Copies: Keep one for your records Return other copy with Steps 2 & 3 Step 2. Fill in the Back on Track Registration Form. Please print clearly and provide all the information required. Step 3. Pay the program registration fee of $578. Please see details in step 3: Program Fee Payment Options. Step 4. Once our office receives your registration forms and payment you will be mailed a list of Back on Track service providers across Ontario. PLEASE NOTE: It is your responsibility to call the service provider in your area to schedule an appointment. If you do not receive this list within 3 weeks of sending payment please contact us at the number below. If you need more information, please contact Back on Track at: Web site: Telephone: (416) (in Toronto) Ontario toll free: Please refer to the enclosed brochure for information about the Back on Track program. For information regarding reinstatement or the Ignition Interlock program please contact Ministry of Transportation at

3 3 Step 1. Participant copy PARTICIPANT AGREEMENT (Participant Copy please keep this copy) About Back on Track Back on Track is Ontario s Remedial Measures Program for Impaired Drivers. It is provided by the Centre for Addiction and Mental Health (CAMH) on behalf of the Ministry of Transportation Ontario, (MTO). CAMH contracts with Local Providers to deliver the program in various locations in the province of Ontario. About the Participant Agreement By signing this agreement, you are giving permission for CAMH to share certain personal information about you with the Ministry of Transportation (MTO). The agreement also allows the Local Providers who deliver the services and CAMH to exchange personal information about you. Signing the agreement also indicates that you understand and agree to the requirements for successfully completing the program. 1. Consent to Release Information I acknowledge that CAMH, on behalf of the MTO, will be collecting personal information 1 from me. The Local Provider may also collect personal information from me on behalf of CAMH. CAMH will keep this information in a client record in an encrypted database. CAMH and/or the Local Provider may also keep progress notes. All personal information that I provide to CAMH and/or the Local Provider will be kept as part of my client record. This information relates to my identity, program enrolment and participation, and responses to the assessment questions, if applicable. I further acknowledge and consent to the release of this personal information as follows: MTO may receive specific personal information relating to my status in the program and the result of each program component. If applicable, MTO will also receive any recommendation for medical review. This information will be sent by CAMH to MTO through an encrypted file on the Internet, through secure facsimile transmission, by registered mail or by courier. If applicable, the Local Provider that is contracted by CAMH to deliver the program may have access to all the personal information in my client record while I am in the program and may exchange the information about me with the MTO and CAMH. The Local Provider will have access to my client record in CAMH s encrypted database using the Internet. Once I have completed the program with the Local Provider, only CAMH will have access to my client record unless I give written consent to do otherwise. 2. Requirements for Successfully Completing Back on Track I understand that to successfully complete the program, I must meet the following requirements: I must not use alcohol or drugs (except medication as prescribed by a physician) within 24 hours of or on any day that I participate in the program. 2 Continued on next page 1 Collection of the personal information as described above is for the administration and operation of the Remedial Measures Program. The authority for the collection and use of this information is in accordance with the Highway Traffic Act, R.S.O. 1990, Chapter H. 8, Section 41.1(6.1) and Section 57(6). If you have any questions about the information collected on this form, please contact the Program Advisor, Licensing Services Branch, Driver Improvement office, Ministry of Transportation, Building A, 2680 Keele Street, Downsview, Ontario M3M 3E6, or If you are not sure you can meet this condition, you should complete substance abuse treatment before you register for Back on Track. Contact CAMH Information at , in Toronto at for help in locating treatment programs in your area.

4 I must attend all sessions as scheduled for me and arrive on time for each session unless I give 24 hours notice that I am unable to attend. The only acceptable reasons for missing a session without giving 24 hours notice are serious illness, a death in my immediate family, jury duty or severe weather. If I miss a session I must provide a document (e.g., a doctor s note) to support my reason. I must reschedule the missed session and complete all assignments. I must provide accurate information about myself and my remedial requirement. I must participate fully in the program activities and demonstrate that I have learned about separating my drinking from my driving. I must treat the program staff and other participants with respect. Verbal or physical abuse will not be tolerated. If I do not meet the program requirements successfully for any reason, I have failed the program. I may register for the program again but I must pay the program fee again. I will be required to take an assessment, either an education or treatment component and then complete a follow-up interview six months later to meet the MTO remedial requirement. This could delay completing my remedial requirement by a minimum of 11 months. 3. Conditions I also understand the following conditions: The program fee is non-refundable. The requirement to complete all components before my licence can be reinstated and that the process may take up to 11 months to complete. If I do not complete my remedial requirement within my suspension period, my licence will remain suspended until I have completed all three program components. I am responsible for any travel costs to attend any program component. The program is offered in English. In designated areas it is offered in French. If I need a language interpreter, translator or any other special arrangement to participate fully in the program, I am responsible for making the arrangements and paying any associated costs. Program staff may decide that I require a translator or other special arrangements to meet the program requirements. The interpreter/ translator must be 18 years of age or older. Program Accommodations (please check all that apply and indicate any special needs): Hearing _ Physical Disability _ Language other than English or French (translator required) _ Participant cannot read English or French (translator required) _ Special learning needs (please specify): _ If program staff observe that I have a medical condition that they are concerned could affect my ability to operate a motor vehicle safely, they may recommend a medical review to the Ministry of Transportation. I will be informed if such a recommendation is made. Conditions that could result in a medical review include: blackout or loss of consciousness, poor physical co-ordination, a balance problem, visible tremors or shaking, disorientation or confusion, agitated or overly sedated behaviour, and extreme memory problems. I understand and agree to the terms of this participant agreement, including: the requirements for successfully completing the Back on Track Program the consequences if I do not meet the requirements the consent to release personal information. Sign Here Name: Signature: Date: / / (Please print your name as it appears on your driver s licence.) (dd / mm / yy) 4

5 5 Step 1. Registration copy PARTICIPANT AGREEMENT (Registration Copy please send with your registration and payment) About Back on Track Back on Track is Ontario s Remedial Measures Program for Impaired Drivers. It is provided by the Centre for Addiction and Mental Health (CAMH) on behalf of the Ministry of Transportation Ontario (MTO). CAMH contracts with Local Providers to deliver the program in various locations in the province of Ontario. About the Participant Agreement By signing this agreement, you are giving permission for CAMH to share certain personal information about you with the Ministry of Transportation (MTO). The agreement also allows the Local Providers who deliver the services and CAMH to exchange personal information about you. Signing the agreement also indicates that you understand and agree to the requirements for successfully completing the program. Consent to Release Information I acknowledge that CAMH, on behalf of the MTO, will be collecting personal information 3 from me. The Local Provider may also collect personal information from me on behalf of CAMH. CAMH will keep this information in a client record in an encrypted database. CAMH and/or the Local Provider may also keep progress notes. All personal information that I provide to CAMH and/or the Local Provider will be kept as part of my client record. This information relates to my identity, program enrolment and participation, and responses to the assessment questions, if applicable. I further acknowledge and consent to the release of this personal information as follows: MTO may receive specific personal information relating to my status in the program and the result of each program component. If applicable, MTO will also receive any recommendation for medical review. This information will be sent by CAMH to MTO through an encrypted file on the Internet, through secure facsimile transmission, by registered mail or by courier. If applicable, the Local Provider that is contracted by CAMH to deliver the program may have access to all the personal information in my client record while I am in the program and may exchange the information about me with the MTO and CAMH. The Local Provider will have access to my client record in CAMH s encrypted database using the Internet. Once I have completed the program with the Local Provider, only CAMH will have access to my client record unless I give written consent to do otherwise. Requirements for Successfully Completing Back on Track I understand that to successfully complete the program, I must meet the following requirements. I must not use alcohol or drugs (except medication as prescribed by a physician) within 24 hours of or on any day that I participate in the program. 4 Continued on next page 3 Collection of the personal information as described above is for the administration and operation of the Remedial Measures Program. The authority for the collection and use of this information is in accordance with the Highway Traffic Act, R.S.O. 1990, Chapter H. 8, Section 41.1(6.1) and Section 57(6). If you have any questions about the information collected on this form, please contact the Program Advisor, Licensing Services Branch, Driver Improvement office, Ministry of Transportation, Building A, 2680 Keele Street, Downsview, Ontario M3M 3E6, or If you are not sure you can meet this condition, you should complete substance abuse treatment before you register for Back on Track. Contact CAMH Information at , in Toronto at for help in locating treatment programs in your area.

6 Sign Here 6 I must attend all sessions as scheduled for me and arrive on time for each session unless I give 24 hours notice that I am unable to attend. The only acceptable reasons for missing a session without giving 24 hours notice are serious illness, a death in my immediate family, jury duty or severe weather. If I miss a session I must provide a document (e.g., a doctor s note) to support my reason. I must reschedule the missed session and complete all assignments.. I must provide accurate information about myself and my remedial requirements. I must participate fully in the program activities and demonstrate that I have learned about separating my drinking from my driving. I must treat the program staff and other participants with respect. Verbal or physical abuse will not be tolerated. If I do not meet the program requirements successfully for any reason, I have failed the program. I may register for the program again but I must pay the program fee again. I will be required to take an assessment, either an education or treatment component and then complete a follow-up interview six months later to meet the MTO remedial requirement. This could delay completing my remedial requirement by a minimum of 11 months. 3. Conditions I also understand the following conditions: The program fee is non-refundable. The requirement to complete all components before my licence can be reinstated and that the process may take up to 11 months to complete. If I do not complete my remedial requirement within my suspension period, my licence will remain suspended until I have completed all three program components. I am responsible for any travel costs to attend any program component. The program is offered in English. In designated areas it is offered in French. If I need a language interpreter, translator or any other special arrangement to participate fully in the program, I am responsible for making the arrangements and paying any associated costs. Program staff may decide that I require a translator or other special arrangements to meet the program requirements. The interpreter/ translator must be 18 years of age or older. Program Accommodations (please check all that apply and indicate any special needs): Hearing _ Physical Disability _ Language other than English or French (translator required) _ Participant cannot read English or French (translator required) _ Special learning needs (please specify): _ If program staff observe that I have a medical condition that they are concerned could affect my ability to operate a motor vehicle safely, they may recommend a medical review to the Ministry of Transportation. I will be informed if such a recommendation is made. Conditions that could result in a medical review include: blackout or loss of consciousness, poor physical co-ordination, a balance problem, visible tremors or shaking, disorientation or confusion, agitated or overly sedated behaviour, and extreme memory problems. I understand and agree to the terms of this participant agreement, including: the requirements for successfully completing the Back on Track Program the consequences if I do not meet the requirements the consent to release personal information. Name: Signature : Date : / / (Please print your name as it appears on your driver s licence.) (dd / mm / yy)

7 7 Step 2 REGISTRATION FORM Registration Information (Please print clearly) Male Female Date of Birth: / / ( dd / mm / yy ) Required First name (as it appears on your driver s licence): Last name (as it appears on your driver s licence): Current Mailing Address: (unit / apartment #, street) (city, province, postal code) Telephone: ( ) - Cell Phone: ( ) - Work (if permitted): ( ) - (please print clearly to ensure receipt of confirmation) Drivers licence or reference number: - - Please Note: In order to process your forms you must provide your driver s licence number, as we do not have access to this information. You may obtain this information from your court documents, old renewal forms, or by visiting the Ministry of Transportation in person with proper identification. Out of province driver s licence Confidentiality Out of province conviction Back on Track program staff may need to contact you by telephone. May we use the name Back on Track Remedial Measures Program when calling or leaving messages for you? (please check one box) No For reasons of confidentiality, please do not identify the Back on Track Remedial Measures Program when calling or leaving messages for me. Yes You may use the name Back on Track Remedial Measures Program when calling or leaving messages for me. Signature: Date: / / (dd / mm / yy)

8 8 Step 3 PROGRAM FEE PAYMENT OPTIONS The program fee for Back on Track is $578. To register, you must enclose your payment with your Registration Form and signed Participant Agreement. METHOD OF PAYMENT We do not accept cash, line of credit cheques, credit card cheques or personal cheques. We only accept (please choose one of the following): Certified cheque (payable to Back on Track Remedial Measures Program ) Money order enclosed (payable to Back on Track Remedial Measures Program ) Credit card authorization Please charge the total registration fee of $578 to my credit card, payable to Back on Track Remedial Program. Measures Please print Participant name: Credit card (check one): VISA Credit card number: MasterCard Expiry date: / (month / year) Name of cardholder: Signature: Date: / / (dd / mm / yy) SEND ALL YOUR COMPLETED REGISTRATION MATERIALS & PAYMENTS TO: Either mail to: Back on Track Remedial Measures Program 33 Russell Street Toronto, ON M5S 2S1 Or fax your completed registration materials for credit card payment only to: (416) Our Administrative Office is not open to the public. Please do not come in person. Important Once your registration forms and payment have been processed, you will be sent a letter which will include a list of Back on Track service providers across Ontario by mail and (if provided). You must call to schedule your first appointment promptly. If you do not receive this letter within 3 weeks of sending your payment it is your responsibility to contact our office to advise us.

9 9 Optional PROGRAM EVALUATION Dear Participant, You can help us improve Back On Track! We are always working to improve the Back on Track program. To help us do this the Ministry of Transportation will appoint an independent program evaluator. We encourage you to consent to having information about you included in this evaluation. Your consent is voluntary and will not affect your participation in the program. I consent to the release of personal information as follows: An independent program evaluator will be appointed by the Ministry of Transportation. The evaluator may obtain specific personal information about my participation in the Back on Track program from the Centre for Addiction and Mental Health. This information may relate to my place of residence, the place I attend the program sessions, my language preference and any special accommodations I need to participate in the program. Signature: Date: / / (dd /mm /yy) Name: Date of birth: / / (Please print.) (dd /mm /yy) Please return this form with your registration forms if you wish to participate. Thank you for your help. Continued: Please 05U11 turn over

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