Disabled Pass Application Form – Fill Out and Use This PDF

DISABLED DISCOUNT PASS APPLICATION	State of California - Natural Resources Agency
Lifetime Pass - $3.50 application fee	DEPARTMENT OF PARKS AND RECREATION

For persons with permanent disabilities, the Disabled Discount Pass entitles its bearer to a 50% discount for use of all basic facilities (including vehicle day use, family camping, and boat use fees) at any unit of the California State Park System operated by the California Department of Parks and Recreation, except Hearst San Simeon SHM. The pass holder is required to present the Disabled Discount Pass and a valid California Driver License or other suitable photo identification, along with any campsite reservation, and to pay any supplemental fees upon entrance to the park unit.

The pass may be used any day of the week, including holidays, if space is available. The pass is not valid at units operated by local government, private agencies or concessionaires. It is not valid for per-person entry or tour fees (such as museums), group use or sites, special events, commercial use, fees under $2.00 or for supplemental fees and cannot be used in conjunction with any other pass and/or discount. The pass is valid unless revoked and is non-transferable and non-refundable, and cannot be used in conjunction with any other pass and/or discount. A lost or damage pass may be replaced only through reapplication.

To qualify, a person must possess one of the permanent disabilities as defined on the reverse side of this form. Applicants must provide the Department of Parks and Recreation with one of the types of disability certifications listed in Section II below.

Application Instructions: Complete Sections I, II, and III. A doctor must complete Section IV on Page 2 only if qualifying by doctor's

certification. (NOTE: Completed application packets with all attachments will be retained by California State Parks and cannot be returned; please redact sensitive/confidential information.) Submit original, completed application and certification material and copy of valid state-issued driver license or suitable photo identification (minor applicants included), and $3.50 payment to:

If you have questions regarding the Disabled Discount Pass, contact CA STATE PARKS SALES at 1-800-777-0369 ext. 2,

or 916-653-8280. (Information on this form is considered personal. See Page 3 for Privacy Notice.)

I. APPLICANT INFORMATION

*IF APPLICANT IS UNDER 18, PRINT NAME OF PARENT OR GUARDIAN AND ADDRESS (If different than applicant) AND ATTACH COPY OF VALID PHOTO IDENTIFICATION ALONG

WITH MINOR'S PHOTO ID

MAILING ADDRESS				CITY/STATE/ZIP CODE			COUNTRY
PHYSICAL ADDRESS (No P.O. BOXES)			SAME AS MAILING ADDRESS	CITY/STATE/ZIP CODE			COUNTRY
E-MAIL ADDRESS (Username for ReserveCalifornia™ )	PRIMARY PHONE NUMBER (w/area code)			DRIVER LICENSE/ID NO.		Check if applying for replacement pass.
					REASON:

II. IDENTIFICATION AND CERTIFICATION TYPE

Attach copy of applicant's valid driver license/photo ID (interim/temporary not accepted) issued by the state or federal government, or current school ID (and parent/guardian ID if applicable); and the following certification (check one):

1. STATE REGIONAL CENTER CERTIFICATION Attach copy; Letter must be dated within one year of application.

2. DEPARTMENT OF MOTOR VEHICLES (DMV) PERMANENTLY DISABLED STATUS Attach copy of valid non-joint vehicle registration stating disabled status/license OR copy of valid Disabled Person Placard Identification Card/Receipt containing the name of disabled person (copy of placard will NOT be accepted).

3. SOCIAL SECURITY DISABILITY BENEFITS ELIGIBILITY VERIFICATION Attach copy of valid Medicare card and under age of 65, OR copy of current Supplemental Security Income Payment Decision and under the age of 65 dated within one year of application, OR copy of current Social Security Disability Award Certificate and under the age of 65 dated within one year of application.

4. ORIGINAL DOCTOR CERTIFICATION (Doctor must complete and sign Section IV on Page 2 no more than 90 days prior to application submittal . Photocopies/faxes not accepted.)

III. APPLICANT CERTIFICATION

FOR DEPARTMENT USE ONLY

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Issuing office will retain completed applications for one calendar year plus prior calendar year.

IV. DOCTOR CERTIFICATION OF ELIGIBILITY FOR DISABLED DISCOUNT PASS

INSTRUCTIONS TO MEDICAL PROFESSIONAL: Please read through the eligibility requirements. If applicant/patient meets requirements, fill-out the requested information and sign/certify and date below. Must be an original signature using this form. Must be signed/completed/dated no more than 90 days prior to application submittal. Photocopies/faxes not accepted.

DISABLED DISCOUNT PASS ELIGIBILITY REQUIREMENTS

For purposes of this program, a disabled person is defined as anyone who : 1) has a physical or mental impairment which substantially limits one or more of such person's major life activities, and 2) has a current record of such impairment.

To be eligible for a Disabled Discount Pass, the applicant must possess one of the following disabilities:

DEVELOPMENTAL: Persons who meet the legal definition of, or have been identified as developmentally disabled. This includes autism, cerebral palsy, mental retardation, etc.

HEARING: Persons who have total deafness or are unable to hear with the aid of an assistance device on the level that meets the standards of the American National Standards Institute (ANSI), as determined by an audiometer.

MENTAL: Persons who have any mental disorder on the level of severity that restricts activities of daily living, social functioning, or concentration.

PHYSICAL: Persons who have any of the following physical disabilities:

•Mobility: Orthopedic impairments, amputations, or functional limitations where there is: 1) loss or significant impairment of one or both upper extremities; or 2) loss or significant impairment of one or both lower extremities; or 3) impairment of the trunk, back or spine that is a medically diagnosed disability which substantially limits one or more major life activities, impairs or interferes with mobility, or requires the aid of an assistance device for mobility.

•Cardiovascular: Severe cardiac impairment resulting from one of the three consequences of heart

disease: 1) congestive heart disorder; or 2) ischemia with or without necrosis of heart muscle; or 3) conduction disturbances and/or arrhythmias resulting in cardiac syncope; or 4) chronic venous insufficiency, or peripheral arterial disease with intermittent claudication.

•Respiratory: Lung disease to such an extent that forced expiration volume at one second, when measured by spirometry, is less than one liter, or arterial oxygen tension (PO2) is less than 60mm/HG on room air at rest. Also, persons with episodic asthma, chronic bronchitis, etc.

•Neurological: Multiple sclerosis and other neurological disorders such as epilepsy and parkinsonian syndrome.

SPEECH: Persons who have a loss of speech from a glossectomy or laryngectomy, or from cicatricial laryngeal stenosis due to injury or infection that resulted in the loss of voice production by normal means.

VISUAL: Persons whose remaining vision in their better eye, after best correction, is 20/200 or less as measured by the Snellen Test. Also, persons with a substantial limited visual field, by visual efficiency and homonymous hemianopsia, etc.

APPLICANT/PATIENT NAME (First, Middle Initial, Last)

I certify under penalty of perjury that the applicant listed above has one of the disabilities listed above.

DOCTOR'S ORIGINAL SIGNATURE AND DATE

►	DATE:

NOTICE TO EMPLOYEES: The information entered on this form is classified as "personal" under the Information Practices Act (Civil Code Section 1798). The Department's Legal office should be consulted before any disclosure is made.

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DISABLED DISCOUNT PASS APPLICATION (Continued)

PRIVACY NOTICE

Section 1798.17 of the Civil Code requires this notice be provided when collecting personal information from individuals. Each individual has the right to review personal information maintained by this agency, unless access is exempted by law.

TITLE OF OFFICIAL RESPONSIBLE FOR MAINTENANCE OF THE INFORMATION

Staff Park and Recreation Specialist

AUTHORITY WHICH AUTHORIZES THE MAINTENANCE OF THE INFORMATION

Public Resources Code Section 5010 (Amended by stats. 1983, Ch. 524, Sec. 3)

THE FOLLOWING ITEMS OF INFORMATION ARE VOLUNTARY, ALL OTHERS ARE MANDATORY

All information requested on the application is mandatory unless marked as optional.

THE CONSEQUENCES, IF ANY, OF NOT PROVIDING ALL OR ANY PART OF THE REQUESTED INFORMATION

The applicant will not be issued a Disabled Discount Pass.

THE PRINCIPAL PURPOSE(S) WITHIN THE AGENCY FOR WHICH THE INFORMATION IS TO BE USED

The information will be used to determine eligibility for issuance of Disabled Discount Passes allowing 50% discount for use of all basic facilities in state operated units of the State Park System. Applications will be retained one calendar year plus prior calendar year for audit purposes, statistical data, and evaluation of the program.

KNOWN OR FORESEEABLE DISCLOSURES OF THE INFORMATION PURSUANT TO CIVIL CODE SECTION 1798.24, SUBDIVISIONS (e) OR (f)

Departmental Audits Office or Human Rights Office

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