METROLift Application: METRO 0447-20

Have you ever applied for METROLift? Check No or Yes.

Enter the First Name, Last Name, Middle Name and Email.

Enter the Date of Birth (MM/DD/YYYY), Home Phone Number and Mobile Number.

Enter the Address, Apartment Number, City and Zip Code.

Enter the Apartment Complex Name and Gate Code.

If different from home address, enter the Mailing Address, City, State and Zip Code.

Sign the Applicant Signature (required) line and enter the Date.

Enter the Name of Emergency Contact, Relationship and Emergency Mobile Phone.

Line 1: State your disability or disabilities.

Line 2: Check all that apply for the assistive device(s) you use when traveling: Support cane, Manual wheelchair, Trained service animal, Crutches, Powered wheelchair, Communications device, Walker, Power scooter, White cane, Leg brace(s), Portable oxygen, None or Other (describe).

Line 3: Enter the nearest street intersection to your home (Example: Polk & Wayside).

Line 4: Can you walk or use your wheelchair or assistive device(s) from your home to that intersection without assistance? Check Yes or No. If no, please explain.

Line 5: Can you find your way to a bus stop without getting lost? Check Yes or No. If no, please explain.

Line 6: How long can you stand and wait for a bus? Check 15 minutes, 10 minutes, 5 minutes or Less than 5 minutes.

Line 7: All buses have a "destination sign" in front, which shows the route name and number. Check Yes or No for each: Can you read a bus destination sign? Can you ask the driver where the bus is going? Can you give or write a note to the driver? Can you understand the driver's answer? If "no" to any questions, please explain.

Line 8: If you were on the bus, could you pay the fare by putting money in the fare box, or by tapping the METRO Q Card on the Q box? Check Yes or No. If "no" please explain.

Line 9: If you were on the bus, could you recognize the place where you wanted to get off the bus? Check Yes or No. If "no," please explain.

Line 10: Tell about the times when you can use METRO's local fixed-route bus service (Example: if short distance to bus stop; take attendant; need to get somewhere).

Line 11: Check No or Yes: Have you ever received "orientation and mobility training" or "travel training?" If "yes," please list any METRO bus routes on which you can travel.

Line 12: Tell the reasons you feel you cannot use METRO's local fixed-route bus service for some or all trips.

Line 13: How do you currently travel (self, family, friends, bus, rail, METROLift, etc.)? Please explain.

Line 14: Do you require someone to travel with you? Check Yes or No. If "yes," please explain.

Line 15: Can you wait independently alone at your residence and places to which you travel? Check Yes or No. If "no," please explain.

You state that the information you have provided is true and accurate.

You authorize the release of diagnostic and functional information as requested on pages 5 and 6 to METRO for the sole purpose of making a determination regarding your eligibility for paratransit service (METROLift) and understand that personal and medical information will be kept confidential.

You understand that intentionally providing false or misleading information or refusal to undergo an in-person interview assessment is grounds for denial of METROLift services.

If approved, you agree to follow the rules and guidelines established by METROLift and to promptly inform METROLift of any changes in your residence, phone number and, if applicable, your representative's name and phone number; and any significant change in your condition that would affect your level of mobility.

You understand that failure to follow proper procedures or cooperate with METROLift staff, demonstrating illegal or disruptive behavior or, if your condition at any time poses a direct threat to the health or safety of others, such situations may result in either suspension and/or termination of service.

Sign the Applicant's Signature line and enter the Date.

Enter the preparer's Name (please print), Mobile Phone, Relationship, and the Preparer's Signature and Date.

Step 3: Fax or mail in the completed application, along with your physician certification form, to METROLift Eligibility. Fax: 713-652-4338. Mail: P.O. Box 61429, Houston, Texas 77208-1429.⁠^[2]