DRAFT ADA PARATRANSIT APPLICATION - Metro Transit

Professional Verification Page 2 of 2For applicants who have a cardiac condition—American Heart Association Classification:_________________Precautions regarding activity:_______________________________________________________Precautions regarding extreme heat and cold (in terms of activity level as well as tolerance tositting/waiting):_____________________________________________________________________________________________________________________________________________________For all applicants--Please describe how the applicant’s disability prevents him or her from usingMetroBus or MetroLink.________________________________________________________________________________________________________________________________________________________________For all applicants--Please list any activity or environmental precautions:________________________________________________________________________________________________________________________________________________________________The disability is _____ Permanent or_____Temporary.If the disability is temporary, expected duration is_______ months.Your professional area of specialization is, check one:❒Audiologist❒Registered Nurse/Licensed Practical Nurse❒ Rehabilitation Specialist ❒Physical/Occupational/Speech Therapist❒Physician❒Independent Living Specialist❒Optometrist❒ Psychologist❒Social Worker❒ Other:_________________________________Your Name/Title: _____________________________________________________________Agency/Company Name: _______________________________________________________Professional License # (if applicable): _____________________________________________Office Address: _______________________________________________________________Office Phone #: (______) ________ -- _____________Fax: (______)________ --__________I hereby certify that the above information is true. Metro (1) may verify the validity of the professionalproviding the certification, (2) make the final determination on an applicant’s eligibility for ADAParatransit Service.____________________________________Signature________________________Date10