Registration and ADA Confirmation Form

Delta Area Transit Authority

2901 27th Avenue North

Escanaba, MI  49829

906-786-1186

906-786-0036 FAX  

  

Please print all information clearly.  Thank you.

 
Section 1:  Passenger Information
 

Name:  ________________________________________________________________

 

Home Address:  ________________________________________________________

 

Name of Building or Complex (if applicable) ____________________________

 
Apartment number:  ________________ City:  ­­­___________________________
           

Zip:  _____________ Date of Birth:  _____________________________________

 

Home Phone:  _____________________ Cell Phone:  _______________________

 
 
 

Section 2:  Please check all areas that apply to your travel needs:

1.      I use mobility aids

            ____ Manual Wheelchair             ____ Electric Wheelchair

            ____ Amigo/Power Scooter        ____ Cane

            ____ Walker                                      ____ Crutches

____ Guide Dog                              ____ Personal Wheeled Cart
2.      ____  I need to travel with staff while on the bus.
 
3.      ____  I have a vision impairment
 
4.      ____  I have a hearing impairment
 
5.      ____  I travel with oxygen
 

6.      Any other information that DATA needs to be aware of: 

_____________________________________________________________________
 
_____________________________________________________________________
 
_____________________________________________________________________
 
                                            
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Section 3:  Emergency Contact Information

List the names of two people and/or agency (if appropriate) which may be contacted in case of an emergency:

 
Contact Name #1______________________________________________________
 

 Phone ________________________Alternate Phone ________________________

 

Address:_______________________________________________________________

 

Relationship:  __________________________________________________________

 
------------------------------------------------------------------------------------------------------------
 
Contact Name #2______________________________________________________
 

 Phone ________________________Alternate Phone ________________________

 

Address:_______________________________________________________________

 

Relationship:  __________________________________________________________

 
 

Section 4:  ADA Verification Any passenger (other than senior citizens) who is eligible for the reduced fare under the Americans with Disabilities Act (ADA) needs to have a medical doctor or mental health professional complete this section.   

 

I attest that ___________________________________________________ (name) is eligible for the reduced fare based on their ADA qualifications.

 
Signature:  _________________________________________________________

Name of Professional:  ______________________________________________

Agency (if applicable): _____________________________________________

City ______________________ State _________________ Zip _______________

Phone Number:  _____________________________

Reminder:  A separate form must be completed for each family member.

 

Return your completed application to:

Delta Area Transit Authority

2901 27th Avenue North

Escanaba, MI  49829
 

  






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