Personal Information
Home Address
Mailing Address
(If different from above)
Emergency Contact
Alternative Format Information
Mobility Information
Treatment Plan
Bus and Light Rail Usage
Travel Training

Valley Metro may need to contact your rehabilitation professionals or healthcare providers for additional information on how your disability prevents you from using bus or light rail service. Please list licensed or certified rehabilitation or health professionals who can provide information about your abilities. All information will be confidential and only utilized to determine eligibility for ADA Paratransit Service.

Medical Contact Information
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.

Please call (602) 716-2100 to schedule an appointment. You must bring a valid photo identification to your in-person assessment appointment.