City, State, Zip:________________________________________________________________
Daytime Phone:______________________________ Evening Phone:____________________
Please describe the disability or health condition that prevents you from using fixed route buses (Valley Metro). Please list all disabilities or health conditions that apply.
Is this disability or health condition temporary? _____Yes _____ No
If yes, how long do you expect it to prevent you from using fixed route buses?
Do you ever need to bring someone with you when you travel (a personal care attendant)?
Yes, always Yes, sometimes No
How do you currently travel to your most frequent destinations?
Bus Drive Myself Taxi Someone drives me
Please read the following statements and check those which best describe your abilities to use fixed route buses. (Check all that apply).
Fixed route buses means the large city buses operated on set routes by Valley Metro.
I can get to and from bus stops if the distance is not too great.
I can ride the bus when I am feeling well. There are other times, however, when my disability or health condition worsens, and at these times I cannot ride the buses.
I have a disability or health condition which prevents me from riding the buses or trains if the weather is very hot or very cold.