Name *

First Name

Last Name

Phone (Day) *

(###)

###

####

Phone (Evening)

(###)

###

####

Is your medical condition and/or disability temporary? *

(If your condition is temporary your application will be reviewed every six months)

Yes

No

Does your disability prevent you from getting to and from a bus stop? *

Yes

No

Can you recognize your destination? *

Yes

No

Do you have difficulty in receiving verbal or written directions? *

Yes

No

Is there a physical barrier that combines with your disability that prevents travel to and from the bus stop? *

(Example: Stairs, No Sidewalks, No curb cuts, Heat, Cold, Ice, Snow, etc.)

Yes

No

Sometimes

Have you ever received SMTD bus training or mobility training?

Yes

No

Do you require assistance when traveling? If yes, check all that apply.

An "A" will be added to your ADA number if you have checked items for which no service can be provided by the driver and you will be required to have someone help you. The Access Sangamon staff will monitor passengers´ abilities as they ride Access Sangamon. If at anytime it is determined through these observations that the rider needs additional assistance to be able to safely use the service, the rider will be notified by Sangamon Mass Transit District that an "A" is being added to their eligibility number. The rider must make arrangements for the assistance that is necessary or ridership will be denied. Access Sangamon will not transport individuals who cannot be transported safely. The rider may appeal this decision in writing to Appeal Access Sangamon, Sangamon Mass Transit District, 928 South Ninth Street, Springfield, Illinois, 62703.

Assistance from your door to the bus

Assistance from the bus to the door

Assistance boarding and deboarding

Assistance with packages

Assistance with mobility devices

Phone

(###)

###

####