application - City of Madison

Metro Paratransit
In-Person Assessment Form: Bring completed form to your assessment.
Medicaid Number:______________________________
Title (circle one): Mr. Ms. Dr.
Last Name _____________________________ First Name_______________________ M.I._____
Current Address_______________________________________________ Apt. #:______________
City: ____________________________________ State: ______________ Zip Code: ____________
Name of Residence (if appropriate):____________________________________________________
Phone Numbers/Home: ___________________________ Cell: ______________________________
Date of Birth: _______________________
Age: _______
Sex: [ ] M [ ] F
*Bring current ID and/employer or school bus pass.
Mailing Address: where any written information/notification concerning Metro Paratransit should be
sent (only one address for mailing purposes please):
[ ] Same as applicant Address, or
Address:_______________________________________________________________________
City: ____________________________________ State: ______________ Zip Code: ____________
Contact Person’s Name (if applicable):______________________________________________
Phone: __________________________ Agency: _______________________________________
In case of an emergency, list the names of two people, physicians, family, agencies or others familiar
with your disability, that Metro can contact:
Name:________________________________Work/Cell#_______________Home#______________
Address:__________________________________________________________________________
City:_____________________________________ State:_______________ Zip code:____________
Relationship________________________________________________________________________
Name:________________________________Work/Cell#_______________Home#______________
Address:__________________________________________________________________________
City:_____________________________________ State:_______________ Zip code:____________
Relationship________________________________________________________________________
What is your disability/ diagnosis?
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Do you use a wheelchair or scooter : How wide is it? __________ inches.
How long is it? _________ inches. How heavy is it when occupied (total weight)? ___________ pounds
*This information is not used to determine paratransit eligibility. It is the applicant’s responsibility to
know the dimensions of their mobility device and whether it exceeds the minimum standards specified in
the ADA.
*METRO must be able to verify your stated disability. Please include support documents
relating to your disability and be prepared to explain the reasons you are able and unable to
use METRO’s fixed route bus service. If you have a medically defined heat/ cold sensitivity,
please provide medical documentation of the range of temperatures you can tolerate.
To verify your disability, please list the names of two professionals, which may include physicians,
agencies or others familiar with your disability, if verification of information is required:
Name:______________________________________ Telephone #:__________________________
Address:______________________________________Title:________________________________
City:___________________________________________ State:_________ Zip Code:____________
Name:______________________________________ Telephone #:__________________________
Address: _____________________________________Title:_________________________________
City:___________________________________________ State:_________ Zip Code:____________
Release of Information
I, the applicant, understand that the purpose of this application form is to determine my eligibility to use
Metro Paratransit Service. I agree to release the information requested to Metro and any eligibility review
panel, and understand that the information contained herein will be treated confidentially. I understand
further the Metro reserves the right to request additional information at its discretion. I also allow Metro
Paratransit Service to refer and exchange applicant information with the Dane County Travel Training
Program. Original signature required. Copies or facsimiles of signatures will not be accepted (please do
not fax or email this form).
Signature of Applicant___________________________________________Date_______________
Printed Name of Applicant___________________________________________________________
Printed Name of Preparer____________________________________________________
If preparer represents an agency, please print the agency name here:
__________________________________________________Phone #________________
Signature of Parent or Legal Guardian ________________________________Date_______________
Printed Name of Parent or Legal Guardian________________________________________________
I ______________________ (print name) completed this application and am responsible for its truth
and accuracy. Thank you for completing this application form.
Please Bring Completed Form and Documents to Your In-Person Assessment
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