Application Access Ride – Fill Out and Use This PDF

The Application Access Ride is a service offered by the Metropolitan Area Transit Authority (MATA) that provides free transportation to those who are disabled.

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Application Access Ride PDF Details

When you need to take a trip and don't have access to a car, or when you just want an easy, affordable way to get around town, the application access ride form is the perfect solution. With this convenient service, you can easily hail a ride from your phone. Plus, there are no extra costs or fees associated with using this service. So whether you're going to work, the grocery store, or running errands, application access rides will get you where you need to go. Check out this quick guide to learn more about how it works.

The listing has got details about the application access ride. Prior to fill in the form, it is definitely worth studying more details on it.

Question	Answer
Form Name	Application Access Ride
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	access a ride application 2020, access a ride application 2021, access ride application, access a ride application pdf

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ACCESS-A-RIDE SERVICE APPLICATION

❑ New Application

❑ Recertification: ID Number ____________________________

MTA New York City Transit’s paratransit service, Access-A-Ride, provides door-to-door transportation within New York City on an advance reservation basis to persons who, because of a physical or mental disability, are unable to use public transit buses or subways.

INSTRUCTIONS

You must complete this application and bring it with you to the scheduled evaluation at the offices of the professional certifier selected by NYC Transit listed in the cover letter. Please give the completed application and any supporting documents to the professional certifier.

If a question does not apply to you, clearly mark N/A in the space provided. If you have any questions while completing this application, please call 877-337-2017 and when the recorded message begins press “1” for English and “1” for Eligibility. If you are unable to complete the form yourself, it can be completed by someone you choose to assist you. It may take up to 3 weeks to process your application.

One (1) photograph taken within the last three years must be submitted with this application for use on your identification card. Please see the box below for required size. The photograph must have a solid background and show a full view of your face. Please write your name on the back of the photograph. If you do not bring

the photograph with you to the evaluation center, the application process cannot be completed.

All of the information you provide will be used solely for the purpose of determining your eligibility, and any special assistance you may need when using paratransit. The information that you furnish will be kept strictly confidential.

Once issued, an Access-A-Ride paratransit service card expires five (5) years from the date it was issued, unless otherwise indicated.

Do you need information in an alternate format?

Check one: ❑ Large Print	❑ Audio Tape	❑ Braille
❑ E-mail _________________________________			2"
Address
Your evaluation will not take place if you arrive at the evaluation
center with an incomplete application. You will have to
reschedule your evaluation and you may not be provided with

				1 1/2"
transportation for the rescheduled evaluation.
transportation for the rescheduled evaluation.

For External Certifier’s Use

Initials _________________________

Date ____________________________

For NYCT Office Use

Application #: ______________________

Date Entered: ______________________

By: ______________________________

AGREEMENT TO ELIGIBILITY TERMS AND CONDITIONS (ALL APPLICANTS MUST SIGN THIS AGREEMENT)

I understand that as a part of the application process I must attend an in-person evaluation at the offices of a professional certifier selected by NYC Transit.

I understand that MTA NYC Transit reserves the right to request additional proof of my disability or my inability to use public buses and subways.

I understand that my application will not be accepted at the evaluation center if it is not complete.

I affirm that all of the information that I provide on this application is true to the best of my knowledge. I understand that my application is subject to review and verification, including verification after my Access-A-Ride card has been issued, and that misrepresentation of any material information will lead to termination of my eligibility.

I agree to notify NYC Transit at 877-337-2017 if I no longer need paratransit service for any reason, including a change in my ability to use bus and subway service. I also understand that my failure to cooperate with a request for additional information to verify statements made on my application after my Access-A-Ride card has been issued will be grounds for suspension or termination of my eligibility for paratransit service. I further understand that my failure to adhere to the policies and procedures for using Access-A-Ride are also grounds for suspension or termination of my eligibility for paratransit service.

_____________________________________________	_____________________________________________
Applicant’s Signature	Date

If someone other than the applicant has completed this application, please provide the following information:

_____________________________________________	_____________________________________________
Name	Relationship to Applicant
_____________________________________________	_____________________________________________
Telephone Number	Date

REQUIRED IDENTIFICATION INFORMATION (PLEASE PRINT CLEARLY)

____________________________________ ____________________________________				___________
Last Name	First Name			M.I.
________________________________________________________			______________________________
Street Address			Apt. No.
_______________________________________________		_______	_______________________________
City/Borough		State	Zip Code

________________________________________________ and ____________________________________________

Cross Streets

___________-_____________-_____________________		__________-_____________-______________________
Home Telephone Number		Work Telephone Number
______________________________________________		__________-_____________-______________________
E-mail Address		Cell Phone Number
_________-__________-__________	Sex: ______	______
Date of Birth	Male	Female

If your mailing address is different from your home address, please complete the following:

(Otherwise leave blank)

____________________________________________________________		_____________________________
P.O. Box or Street Address		Apt. No.
______________________________________________________	________________		__________________
City/Borough	State		Zip Code

Person to Contact in Case of Emergency: (This section must be completed.)

____________________________	____________________________ _______
Last Name	First Name	M.I.
_____________-____________-__________		_____________-____________-__________
Home Telephone Number		Work Telephone Number

Relationship to Applicant: _______________________________________

APPLICATION FORM

1.How do you currently travel? (Check all that apply)

❑ Public Transit Bus ❑ Subway ❑ School Bus ❑ Walking ❑ Automobile

❑Access-A-Ride ❑ Commuter Railroad

❑ Ambulette

❑ Taxi/Car Service

❑ Other: ____________________________________________

2.Are you registered with the MTA Reduced-Fare program?

❑ Yes

❑ No

3.Do you have a MetroCard? (Check all that apply)

❑Yes, I use my MetroCard when traveling by bus

❑Yes, I use my MetroCard when traveling by subway

❑No, I don’t have a MetroCard

4.Is your disability:

❑ Permanent ❑ Temporary ❑ I don’t know

5.If temporary, please indicate how long you believe the temporary disability will continue.

❑2 months ❑ 3 months ❑ 6 months

❑Other (Specify): ___________________________________

6.Indicate which support device(s) you use when traveling or walking outside your home.

❑I do not require a support device

❑ Respirator/Oxygen Tank	❑ Walker	❑ Braces
❑ Support Cane	❑ Scooter*	❑ Crutches

❑Prosthesis

❑Service Animal (an animal that provides assistance)

❑Manual Wheelchair*

❑Motorized Wheelchair*

❑Other (Specify) ______________________________________________

*Access-A-Ride vehicles can only accommodate a wheelchair or scooter that is less than 33.5 inches in width and 51 inches in length and does not weigh more than 800 pounds when occupied.

7.If you have a service animal, indicate the tasks(s) your service animal performs for you.

❑Guides me (vision impairment)

❑Alerts me (hearing impairment)

❑Pulls me (manual wheelchair)

❑Carries items for me

❑Other (Specify): _____________________________

8.Have you received training to use public transit buses or subways?

❑ Yes

❑ No ❑ No, I would like training

❑I am in the training process

9.Would you be able to travel by bus or subway if Access-A-Ride took you from: (Check all that apply)

❑your home to a bus stop

❑the bus stop to your home

❑your destination back to the bus stop

❑your home to an accessible subway station

❑the accessible subway station to your home

❑your destination back to the accessible subway station

❑Not applicable

10.a. How far from your home is the nearest public transit bus stop?

❑ Less than 1 block ❑ 1 to 2 blocks ❑ 3 to 4 blocks ❑ 5 or more blocks

Identify location of public transit bus stop:

___________________________________________________________________________

b. How long does it take you to walk to the nearest public transit bus stop?

❑ Less than 5 minutes	❑ 5-10 minutes
❑ More than 10 minutes	❑ Not sure

11.On your own or using a support device, are you able to get to and from the public transit bus stop nearest your home?

❑ Yes

❑ No

❑Sometimes—describe the circumstances:

___________________________________________________________________________

12.On your own or using a support device, can you get on, ride, and get off a public transit bus when the “kneeler” is lowered (a kneeler is a device that lowers the front of the bus)?

❑ Yes

❑ No

❑ Sometimes—describe the circumstances: _______________________________________________________________________________

13.How often do you travel on public transit buses?

❑	Daily ❑ Weekly ❑ Monthly
❑	Occasionally ❑ Never

If you have used a public transit bus in the past, when did you stop?

____________ (Mo./Yr.)

Why did you stop traveling by public transit bus?

_________________________________________________________________________________________________________________

14.If you cannot walk up the steps on a bus or use the kneeler, are you able to use the bus lift? (Please note that persons who cannot climb the bus steps have the right to enter the bus by standing on the lift.)

❑ Yes ❑ No

❑ Sometimes ❑ Don’t Know

15.Are you able to identify and understand the destination and route number signs on public transit buses?

❑ Yes

❑ No

❑Only when the bus operator announces them

❑Sometimes—describe the circumstances: _______________________________________________________________

16.Are you able to determine when you have reached your destination to get off the public transit bus?

❑ Yes ❑ No

❑Only when the bus operator announces the stop

❑Sometimes—describe the circumstances:

______________________________________________________________________________________________________________________________________________________________________

17.a. How far from your home is the nearest subway station?

❑ Less than 1 block ❑ 1 to 2 blocks

❑3 to 4 blocks ❑ 5 or more blocks

Identify location of subway station:

_______________________________________________

b. How long does it take you to walk to the nearest subway station?

❑	Less than 5 minutes	❑ 5-10 minutes
❑	More than 10 minutes	❑ Not sure

18.On your own or using a support device, are you able to get to and from the subway station nearest your home?

❑ Yes

❑ No

❑ Sometimes—describe the circumstances:

_________________________________________________________________________________________________________

19.On your own or using a support device, can you ride on an escalator?

❑ Yes ❑ No

❑ Sometimes—describe the circumstances: _________________________________________________________________

20.On your own or using a support device, are you able to go to and from the station platform and the street entrance?

❑ Yes

❑ No

❑Sometimes—describe the circumstances: _____________________________________________

❑Only if equipped with an elevator

21.On your own or using a support device, how far can you travel on a level street? Please answer in city blocks.

❑	Less than 1 block	❑ 1 to 2 blocks
❑	3 to 4 blocks	❑ 5 or more blocks

22.On your own or using a support device, can you get on, ride and get off a subway train?

❑ Yes ❑ No

❑Sometimes—describe the circumstances: ________________________________________

23.Are you able to determine surfaces (platform, top or bottom of stairs) in a subway station?

❑ Yes ❑ No

❑ Sometimes—describe the circumstances: ______________________________________________________

24.Are you able to identify and understand the destination and subway line signs?

❑ Yes ❑ No

❑Sometimes—describe the circumstances:

_______________________________________________________

25.Are you able to determine when you have reached your destination to get off the subway?

❑ Yes ❑ No

❑Sometimes—describe the circumstances:

______________________________________________________

❑Only when the conductor announces the stop

26.How often do you travel using the subway?

❑Daily ❑ Weekly ❑ Monthly ❑ Occasionally

❑Not at All

If you have used the subway in the past, when did you stop using it?

___________(Mo./Yr.)

Why did you stop traveling by subway?

______________________________________________________________________________

27.a. Do you currently travel with a Personal Care Attendant (PCA), a person such as a home attendant who assists you regularly when you travel outside your home?

❑ Yes

❑ No

❑Sometimes—describe the circumstances:

__________________________________________________________________________________

❑I don’t have a Personal Care Attendant

b.If you do need the assistance of a PCA to travel, what kind of traveling assistance does the PCA provide and what specifically does the PCA do for you when he/she travels with you?

_____________________________________________________________________________________________________________

28.If you are unable to take some or all of your trips by public transit bus or subway, check off the reasons below. (Check all that apply)

❑Not applicable

❑I feel unsafe traveling by public transit bus

❑I do not like traveling by city buses

❑Distance to public transit bus is too long

❑I do not like traveling by subway

❑I feel unsafe traveling by subway

❑Distance to subway is too long

❑Subway station has no elevators

❑No curb cuts

❑No paved sidewalks

❑Inclement weather

❑Extreme cold

❑Hilly streets

❑Extreme heat

❑I cannot travel to an unfamiliar place

(The application continues on Page 9).

29.a. From the following list, please check off all disabilities or conditions that prevent you from boarding, riding or disembarking from public transit buses or subways.

Cardiovascular/Pulmonary				Neuromuscular
Angina			___	ALS/Lou Gehrig’s Disease		___
Arteriosclerosis/Atherosclerosis			___	Cerebral Palsy		___
Asthma			___	Charcot-Marie Tooth Syndrome		___
Bypass Surgery:	Date: _________________			Equilibrium		___
Chronic Obstructive Pulmonary Disease			___	Fibromyalgia		___
Congestive Heart Failure			___	Hemiplegia/Hemiparesis		___
Cystic Fibrosis			___	Multiple Sclerosis		___
Emphysema			___	Muscular Dystrophy		___
Heart Attack:	Date: _________________			Neuropathy		___
HTN/Hypertension			___	Paraplegia		___
Peripheral Vascular Disease			___	Parkinson’s Disease		___
Phlebitis			___	Polio		___
Thrombosis			___	Quadriplegia		___
Other: ___________________________________				Sciatica		___
				Spina Bifida		___
General Medical				Stroke/Cerebral Trauma:	Date: ___________
AIDS			___	TIA’s (Transient Ischemic Attack)		___
Atrophy			___	Other: ___________________________________________
Chemotherapy Treatment dates: _______________
_________________________________________				Orthopedic
Diabetes			___	Amputation: specify extremity (ies) __________
Edema			___	_________________________________________________
Epilepsy			___	Broken/Fracture: __________ Date: ___________
HIV			___	Degenerative Joint Disease		___
Lupus			___	Gout		___
Rheumatoid Arthritis			___	Hip Replacement		___
Kidney Dialysis			___	Knee Replacement		___
Radiation Treatment dates: ___________________				Osteoarthritis		___
________________________________________				Osteoporosis		___
Other: __________________________________				Scoliosis		___
				Spondylitis		___
Vision [Specify eye (s)]		One Eye	Both Eyes	Other: __________________________________
Cataracts		___	___
Cortical Blindness		___	___	Cognitive/Psychological
Glaucoma (all types)		___	___	Alzheimer’s Disease		___
Macular Degeneration		___	___	ADD/Attention Deficit Disorder		___
Retinal Detachment		___	___	Autism		___
Legally Blind		___	___	Dementia		___
Totally Blind		___	___	Head Trauma		___
Other: ________________________________				Mental Retardation		___
				Panic Disorder		___
				Schizophrenia		___
				Other: __________________________________

Toll free from area codes 212, 646, 718, 347, 516, 631, 914, 845

(Press “1” for English and “1” for Eligibility when the recorded message begins.) From all other area codes

b. For each disability or condition checked on previous page, please describe how it prevents you from boarding, riding or disembarking from public transit buses or subways. You may also include medical documentation to support your disability.

_________________________________________________________________________________________________________________________

c. Bring a copy of medical documentation that verifies your transportation related disability to the in-person assessment.

❑CHECK HERE IF YOU ARE NOT BRINGING MEDICAL DOCUMENTATION TO THE IN-PERSON ASSESSMENT.

30.From your residence, what are the addresses of your three (3) most frequent destinations?

			How Often Do You Travel
			To This Location (Specify)?
Destination Address	Cross Streets	Borough	Daily	Wkly	Mthly

1.


2.


3.

If you have any questions, please contact Access-A-Ride Customer Information between 9 AM and 5 PM, Monday through Friday.

877-337-2017

718-393-4999

Customers who are deaf call through the relay.

PLEASE REMEMBER THAT YOU MUST:

■Submit one (1) photograph measuring 2" x 11/2" that has been taken within the last three (3) years.

■Complete and sign the Agreement section.

■Complete the application answering every question, and bring it with you when you go to the evaluation center.

10	134_10__14pt_MA

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