MetroAccess Application

If you have a physical or functional disability, as defined by the Americans with Disabilities Act (ADA), which limits you from using Capital Metro’s fixed-route accessible buses, you may be eligible for MetroAccess. The information obtained in this certification process may be shared with other transit providers to facilitate your travel in other areas.

This application must be filled out completely, including the verification of eligibility by a qualified professional. Incomplete applications will be returned to applicants.

* Indicates a required field

Please enter all dates in mm/dd/yyyy format. e.g. 04/20/2010
Please enter all phone numbers in xxx-xxx-xxxx format e.g 512-123-1234

* First Name:	Middle Initial:	* Last Name:
* BirthDate:

Home Address
Street:		Apt#:
City:	State:	Zip:
Apartment Complex Name:		Building #/Letter:
Security Gate Code (if applicable):
Home Phone:	Work Phone:

Mailing Address
Street:		Apt#:
City:	State:	Zip:

Neighborhood Environment
How would you describe the area where you live (e.g., very steep hill; long, gradual hill; flat; etc?
Are there sidewalks at your residence? YES NO
Is there a ramp at your residence? YES NO	Is one needed? YES NO
How many steps are there at the entrance to your residence?
Do you use the regular Capital Metro buses now? YES NO
If no or sometimes, what limits or prevents you from using the buses? (e.g. no sidewalks)
What is the most difficult part of riding the bus for you?
What bus routes serve your neighborhood?
What is the closest bus stop to your home? (Please give location).
Can you get to this bus stop by yourself? YES NO
If not, why not?
Can you board the bus by yourself? YES NO
If not, why not?
Have you ever received any training to use the fixed route bus service? YES NO
If not, would you like to participate in training? YES NO
If you do not ride Capital Metro buses, how do you currently travel? (For example, family, friends)

Assistive Devices Used (Check all that Apply)

Manual Wheelchair - Foldable; passenger must be able to transfer to a 4-door sedan without driver assistance.
Manual Wheelchair - Passenger is not able to transfer to a 4-door sedan without driver assistance.
High Wheelchair
Long Wheelchair
Electric Wheelchair
Stroller-Type Chair
Certified Service Animal
Communication Device
Cane/White Cane
Crutches
Wide Wheelchair
Power Scooter
Braces
Prosthetics
Walker (Foldable)
Walker (non-foldable)
Oxygen Tank
Other
Please specify for Other

Preferred Media/Communication Type
Regular Print Large Print Braille Cassette Tape Computer Diskette TDD/Texas Relay Other Please specify for Other Email Please give Email address

MetroAccess Applicant Agreement
I agree that if I am certified for MetroAccess, I will pay the exact fare, if required, for each trip. I agree to notify the MetroAccess office of any changes in my status which may affect my eligibility to use the service. I also understand that failure to adhere to the MetroAccess policies and procedures will be grounds for revoking my application and the right to participate in the program. I understand and agree to hold MetroAccess harmless against all claims or liability for damages to any person, property, or personal injury occurring as a result of my failure to equip or maintain the safety of adaptive equipment or certified guide/service animal that I require for mobility. I have read and fully understand the conditions for service outlined in the MetroAccess Policies & Procedures and agree to abide by them. I hereby authorize the release of verification information and any additional information to Capital Metro for the purpose of evaluating my eligibility to participate in the MetroAccess program. I certify that the information provided in this application is true and correct.
Signature:		Date:
The following Information is to be filled out if the application was completed by a person other than the applicant:
Name:		Phone:
Street:		Apt#:
City:	State:	Zip:

Emergency Contact
Name:		Phone:
Relationship:
Street:		Apt#:
City:	State:	Zip:

This page and the following 2 pages must be completed by a qualified professional (PLEASE PRINT).

METROACCESS
Verification of Eligibility

Please note: All information for verification of eligibility must be provided by a qualified professional. Examples of qualified professionals are:

Caseworker	Chiropractor	Optometrist	Physician
Psychiatrist	Psychologist	Registered Nurse	Social Worker
Licensed Medical Professional		Mental Retardation Professional
Orientation & Mobility Specialist		Counselor from an Established Agency

Please enter all dates in mm/dd/yyyy format. e.g. 04/20/2010
Please enter all phone numbers in xxx-xxx-xxxx format e.g 512-123-1234

* Person Completing Verification:
* Professional Title:
* Agency/Affiliation:
* State of Texas Certification ID#:

Business Address
Street:		Apt#:
City:	State:	Zip:
Business Telephone:

If you mark NO or SOMETIMES to any item below, please explain.

Capital Metropolitan Transportation Authority
2910 East 5th Street | Austin, Texas 78702 | (512) 389-7400
Specific Route Information | (512) 474-1200

MetroAccess Application

METROACCESS Verification of Eligibility

METROACCESS
Verification of Eligibility