Accessible Parking Permit Application I hereby ... - Adelphi University

Accessible Parking Permit ApplicationName: __________________________________________ Date of Birth: _____________________Social Security Number: __________________________________________Home Address:Telephone Number:Please Describe Disability:Name of Physician:Address of Physician:Telephone Number of Physician:I hereby certify that the above statements are true and authorize the physiciannamed above to furnish any information requested by the Coordinator of theOffice of Disability Support Services concerning the diagnosis, prognosis andtreatment of my described condition.Signature of Student: _____________________________________Date: _________

Initial Application Procedure for an Accessible Parking Permit□ Complete the Accessible Parking Permit Application.□ Have your doctor complete and sign the Medical Verification Form.□ Return the completed Accessible Parking Permit Application to the Office ofDisability Support Services.□ Provide License Plate Number: ________________________□ Provide Adelphi University Parking Decal Number: ____________________Window Display Instructions• The Parking Permit must be displayed in the dash of your vehicle any timethat you are using handicapped parking on campus.• The Parking Permit must be renewed annually.• The Parking Permits are issued only to student who are currently enrolled inthe University.• Please be informed that you must also display your NYS or CountyAccessible Parking Pass or Public Safety will ticket your vehicle.

Medical Verification FormIn accordance with the New York State definition of “Severely Disabled Person”, Adelphi University requires thefollowing information:Patient Name__________________________________________________________________Social Security Number _________________________________________________________Please check applicable condition(s):“Severely Disabled Person” shall mean any person who has any one or more of the following impairments, disabilities orconditions, which are permanent in nature.Has limited or no use of one or both lower limbs.Has a neuro-muscular dysfunction, which severely limits mobility.Has a physical or mental impairment or condition which is other than those specified, but is of such nature as to imposeunusual hardship in utilization of public transportation facilities and such condition is certified by a physician dulylicensed to practice medicine in this state as constituting as equal degree of disability (specifying the particularcondition) so as to prevent such person from getting around without great difficulty in accordance with subdivision twoof this section.Please describe Disability:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Describe Limitations in Ambulating (include use of aids to walking such as cane, crutches, walker, braceswheelchair, prosthesis, other):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Is this condition permanent? _______________________I AM A MEDICAL DOCTOR LICENSED TO PRACTICE IN NEW YORK STATE, AND IN MY PROFESSIONAL OPINION, I BELIEVETHAT APPLICANT’S MOBILITY-IMPAIRING CONDITION DOES WARRANT A HANDICAPPED PARKING PERMIT, ACCORDINGTO THE ABOVE DEFINITION OF “SEVERELY DISABLED”.Signature of Physician: ______________________________________________ Date: _______________________________Name of Physician:Physician Address:_______________________________________________ Phone#: ________________________________________________________________________________________________________________N.Y.S. Practicing License Number: _________________________________________________________________________

All decisions regarding issuance of Accessible Parking Permits are madeaccording to New York State Parking Regulations:A qualifying disability is one or more of the following impairments, disabilities or conditions that areboth permanent in nature and affect mobility:1. Use of portable oxygen;2. Legal blindness;3. Limited use, or no use, of one or both legs;4. Inability to walk 200 feet without stopping;5. A neuro-muscular dysfunction that severely limits mobility;6. A Class III or IV cardiac condition (American Heart Association standards);7. Severe limitation in the ability to walk due to an arthritic, neurological or orthopediccondition;8. Restriction because of lung disease to such an extent that forced (respiratory) expiratoryvolume for one second, when measured by spirometry, is less than one liter, or the arterialoxygen tension is less than sixty mm/hg of room air at rest;9. Any other physical or mental impairment not previously listed which constitutes an equaldegree of disability, and imposes unusual hardship in the use of public transportation andprevents the person from getting around without great difficulty.A Temporary Parking Permit may be issued when a person has a temporarily disabling conditionthat makes the person unable to walk without a cane, crutches, a walker or other assisting device.NOTE: Under ADA regulations, an individual with a “transitory and minor” impairment thatis expected to heal shortly is not considered disabled. Short-term impairments will be consideredon a case by case basis.Important: Who Can Certify a DisabilityTo qualify for an accessible parking permit, you must present proof of the disability from a medicaldoctor (MD), doctor of osteopathy (DO), doctor of podiatric medicine (DPM, licensed in NYS only).Only these medical professionals are considered "doctors" as the term is used in this publication. Adoctor licensed in New York or another state may certify for conditions #1 through #8 previouslylisted. Only doctors licensed in New York State may certify for condition #9. A podiatrist must belicensed in NYS, and may certify applicants only for severe disabilities of the foot.It is a misdemeanor under the NYS Penal Law (Section 210.45) to make a false statement or providemisinformation to obtain a parking permit for a person with a disability, and is punishable by finesfrom $250 to $1,000. Additional civil penalties from $250 to $1,000 may also be imposed underSection 1203-a (4) of the Vehicle and Traffic Law. These penalties also apply to doctors providingcertifications, as well as applicants.