River Valley Metro Eligibility Application Form PDF Details

Are you interested in utilizing River Valley Metro's transportation services? If so, you need to take action and submit the eligibility application form. This vital component of becoming an RVMT customer provides key information about your current situation that plays a role in determining if you're eligible for service or not. Keep reading to learn more about RVMT's eligibility application process, what forms are required, how long it takes to make a decision, and other necessary details.

QuestionAnswer
Form NameRiver Valley Metro Eligibility Application Form
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesADA_Eligibility _Application_01 11 metro online form

Form Preview Example

Metro Plus Paratransit

ELIGIBILITY APPLICATION

Form must be filled out completely

Please Return Completed Form to:

River Valley Metro Mass Transit Dist.

 

1137 E. 5000 N. Rd.

 

Bourbonnais, IL. 60914

Personal Information

1.Name

2.email address ________________________________________________

3.Address

 

City

 

State

 

 

Zip

 

4.

Telephone No. (Home)

 

 

 

(Work)

 

5.Date of Birth

Certification

A.I certify that the information I give in this application is true and correct. I understand that falsification of information may result in denial of service. I understand all information will be kept confidential and only the information required to provide the services I request will be disclosed to those who perform those services.

Applicant Signature

Date

B.Person completing form other than applicant (please check one):

I certify that the information provided in this application is true and correct, based upon information given to me by the applicant.

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I certify that the information provided in this application is true and correct, based upon my knowledge of the applicant’s health condition

or disability.

Exceptions or Additions:

Print Name

 

Date

Agency

Signature

Daytime Phone

Relationship to Applicant

Address

City

 

State

 

Zip

Authorization For Release Of Medical/Psychological Records

(Must be completed by applicant, Not Physician)

THIS SECTION IS TO BE COMPLETED BY YOU, THE APPLICANT, AND NOT BY YOUR PHYSICIAN, PSYCHIATRIST OR HEALTH CARE PROFESSIONAL. A SEPARATE FORM MAY BE SENT TO HIM/HER TO CONFIRM THE INFORMATION YOU HAVE PROVIDED.

NOTE: Disability verification by a qualified professional does NOT guarantee eligibility, but it can play a major role in the eligibility determination

process. While verification by a physician is NOT required, it is important that any professional that verifies another individual’s disability be familiar not only with that person’s particular disability, but with an individual’s ability or inability to travel on Metro’s regular bus system. This information is confidential and will

NOT be shared with any other person or agency, with the possible exception of another transit provider or transportation program to facilitate travel in those areas.

NOTE: Only the following professionals are authorized to verify your disability:

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Licenses Physician, Psychiatrist, Physical Therapist (PT), Occupational Therapist (OTR), Certified Rehabilitation Counselor (CRC), and Orientation and Mobility Specialist (O&M).

Name of Professional: ______________________________________________________

Agency: ___________________________________________________________________

Address: __________________________________________________________________

City: _________________________________ State: ___________ Zip: _______________

Telephone Number: ________________________________________________________

Name of Professional: ______________________________________________________

Agency: ___________________________________________________________________

Address: __________________________________________________________________

City: __________________________________ State: ___________ Zip: ______________

Telephone Number: ________________________________________________________

APPLICANT INFORMATION

NAME (PRINT): ___________________________________________________________

SIGNATURE: ___________________________________ DATE: ___________________

PARENT OR LEGAL GUARDIAN INFORMATION *

NAME (PRINT): ___________________________________________________________

SIGNATURE: ____________________________________ DATE: ___________________

*NOTE: Applicant signature or Parent/Legal Guardian signature is REQUIRED for application processing.

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Present Means Of Travel

1.Have you ridden a River Valley Metro’s fixed route bus in the last 3 months?

Yes

No

If No, have you attempted to use a fixed route bus in the last 3 months?

Yes

No

If Yes, please explain what happened

2.What assistance do you need when traveling? Check all that apply

____ Support Cane

____ Electronic Travel Aid

____ Long Cane/White Cane

____ Personal Care Attendant

____ Service Animal

____ Powered Scooter

____ Crutches

____ Prosthesis

____ Wheelchair (Power)

____ Wheelchair (Manual)

____ Walker

____ None

____ Need help transferring to a seat

____ Other

If you use a wheelchair or scooter/cart, is it

_____More than 30 inches wide OR

_____More than 48 inches long, OR

_____Weigh more than 600 pounds when empty?

3.Do you require a Personal Care Attendant (PCA)* when you travel?

Always

Sometimes

Never

If Always or Sometimes, provide name of PCA:

*A PCA is someone designated or employed by a person with a disability to assist that person in meeting his or her personal needs and/or to facilitate travel for a specific trip. A PCA is not a companion.

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Transit Travel/Training Information

1.Do you know where to get off the bus, or can you find out?

Always

Sometimes

Never

If Sometimes, please explain.

2.Have you ever had any training to use the fixed route bus service?

Yes

In Process

No

Disability and Functional Limitation Information

1.Please describe your current disability (list all applicable disabilities).

2.Is your health condition or disability temporary?

Yes

No

If Yes, expected end date ____/____/____

or (____ months)

3.Does your health condition or disability change from day-to-day in ways that affect your ability to use the fixed route bus service?

Yes

No

If Yes, please explain

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4.Are there any other conditions (such as extreme hot or cold weather) that limit your ability to use the fixed route bus service?

Yes

No

If Yes, please explain

5.Can you transfer from one fixed route bus to another?

Yes

Sometimes

No

If Sometimes or No, please explain

6.Can you use the telephone or TTY to make calls?

Yes

Sometimes

If Sometimes or No, please explain

No

7.Can you follow instructions?

WRITTEN INSTRUCTIONS:

Yes

VERBAL INSTRUCTIONS:

Yes

If Sometimes or No, please explain

Sometimes

Sometimes

No

No

8.Are you able to make your way to and from the nearest bus stop to your home, either with or without mobility aids?

Yes

Sometimes

No

If Sometimes or No, please explain

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9.Can you wait outside for 15 minutes?

Yes

Sometimes

Explain if Sometimes or No

No

10.Are you able to travel ¼ mile (4 blocks or less), either with or without mobility aids?

Yes

Sometimes

No

Explain if Sometimes or No

11.If using a wheelchair, are you able to transfer from the chair to a bus seat?

Yes

No

If Yes describe limitations:

Miscellaneous

1.Check all that apply if you are NOT currently riding fixed route buses:

____ I don’t know how to ride the regular fixed route bus.

____ I’m afraid to ride the regular fixed route bus.

____ I don’t want to ride the regular fixed route bus.

____ It is too far to get to the regular fixed route bus.

____ The ground is too uneven or steep for me to get to the bus stop.

____ There are no sidewalks where I live.

____ I need a wheelchair lift or ramp to board the bus.

____ I can use the regular fixed route bus under certain circumstances.

____ I cannot recognize a destination or landmark.

____ Other (Please explain)

2.Are there any other aspects of your health condition or disability that we should know about?

Yes

If Yes, please explain

No

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