Personal Information Last Name * First Name * Middle Name Sex Female Male Date of Birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Year Home Address Street Address * Apartment Number City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Day Phone * Evening Phone Email Address * Mailing Address (If different from above) Street Address Apartment Number City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Legal Guardian Name Emergency Contact Name Phone Relationship Who referred you to the program? Disability Information Category of Disability (Check all that apply) Intellectual/Developmental Deaf or Hard of Hearing Physical Blind or Low Vision Psychiatric Chronic Medical Other (Describe other disability if not listed above) Do you use any mobility devices (Check all that apply)? * None Power scooter Manual wheelchair Crutches White cane Power wheelchair Support cane Service animal Walker Other (Describe other mobility device if not listed above) Do you have any visual or hearing impairments that we should be aware of? * Yes No How far can you walk or travel by yourself? * Less than 1 block 1 block 2 blocks (1/4 mile) 4 blocks (1/2 mile) 6 blocks (3/4 mile) More than 6 blocks Is there a bus stop or light rail station within walking distance? * Yes No Not sure Are you able to cross streets on your own? * Yes No Not sure Destinations List two places you would like to travel on the bus system: Certification and authorization I certify that the information provided in the application is true and correct. I understand that falsification of information may result in denial of service. I authorize the professionals listed above to release to Valley Metro information about my disability and its effect on my ability to travel on the bus or light rail service. Unless earlier revoked, this form permits the professional listed to release information up to 90 days from the date below. Applicant name Person assisting applicant (if any) Leave this field blank Submit
