SMART RIDE Application – Physical Disability
Apply for specialized mobility access and reliable transportation for individuals with physical disabilities or limited access to public transit.
Applicant Information
Full Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Residential Address
*
City/State/ZIP
*
Eligibility Category (select all that apply)
*
Physical Disability preventing safe access to a public transit stop
Residence in an Area Without Public Transit Access
Both disability and inaccessible location
Physical Disability Details
Describe the physical condition affecting your mobility
How does this condition limit your ability to reach or use a transit stop?
Condition impact options (select all that apply)
Unable to walk required distance
Unable to stand for extended periods
Requires mobility aid
Balance or endurance limitations
Other
If 'Other', please describe
Mobility Devices Used (select all that apply)
Wheelchair (manual)
Wheelchair (power)
Walker
Cane
Scooter
None
Other
If 'Other', please describe
Condition Status
Permanent
Temporary
If temporary, expected duration
Location-Based Access Issues
Reason public transportation is not accessible from your residence (select all that apply)
No bus routes within reasonable distance
Unsafe or inaccessible terrain
Rural/isolated area
No sidewalks or safe pedestrian paths
Other
If 'Other', please describe
Nearest known public transit stop (if any)
Distance from your home to nearest stop
Additional Support Needs
Do you require assistance boarding or exiting the vehicle?
Yes
No
If yes, describe assistance needed
Do you travel with a caregiver or companion?
Yes
No
Name of caregiver/companion
Emergency Contact
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Healthcare Provider Verification (Optional but Recommended)
Healthcare Provider Name
Healthcare Provider Practice/Facility
Healthcare Provider Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Healthcare Provider Signature
Healthcare Provider Signature Date
-
Month
-
Day
Year
Date
Applicant Certification & Authorization
Applicant Signature
*
Applicant Signature Date
*
-
Month
-
Day
Year
Date
Office Use Only
Application Received Date
-
Month
-
Day
Year
Date
Eligibility Category
Disability
Location
Both
Approved By
Approval Date
-
Month
-
Day
Year
Date
Office Use Notes
Submit Application
Submit Application
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