Fixed Route Reduce Fare Program APPLICATION Applicant: Fill out the information on page one (1). Information must be complete, accurate and legible. When you have completed page one (1), please have a licensed physician or psychiatrist complete the remainder of the application. If you have any questions about your application, call (937) 425-8444 or Ohio Relay 711. Physician/Psychiatrist: Complete pages two and three (2-3). Information must be complete, accurate and legible. When application is complete, please mail to: RTA Certification Center: 4th S. Main Street, 2nd Floor Dayton, Ohio 45402 (937) 425-8444 –or– Ohio Relay 711 General Information: The Eligibility Criteria of the application assist Greater Dayton Regional Transit Authority determine if the applicant may be eligible for the Fixed Route Reduced Fare Program. Reduced Fare Identification Cards for persons with a permanent disability are valid for a five (5) year period. Identification Cards for persons with a temporary disability are valid until the expiration date provided by physician. Eligibility for a Reduced Fare Identification Card is based on the applicant’s physical or mental disability, or an impairment that limits one or more major life functions as defined by the Americans with Disabilities Act (49 CFR Part 37). Any fees charged for the completion of the application are not the responsibility of Greater Dayton Regional Transit Authority. Information on the application is confidential. Exclusions: Persons whose sole incapacity is any reasons listed below they are excluded from Reduced Fare eligibility. Pregnancy Obesity Contagious disease Acute or chronic alcoholism or drug addiction
PHYSICIAN CERTIFICATION (to be completed by licensed physician or physiatrist) Part 1 – Please stamp name and address Physician/Psychiatrist Physician/Psychiatrist Address Physician/Psychiatrist Phone Number Physician/Psychiatrist Fax Number Signature of Physician/Psychiatrist Date ELIGIBILITY CRITERIA Part 2 Is the impairment or disability temporary? Yes No If temporary, what is the estimated period of time? From to Date Date PHYSICAL DISABILITIES Part 3 – These four questions must be answered completely Complete this section if the applicant has physical disabilities or impairments: A physical impairment is defined by the ADA as: “Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: Neurological, musculoskeletal, special sense organs, respirator (including speech organs), cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic, skin, and endocrine.” 1. What is the applicant’s specific disability or impairment: 2. Describe the applicant’s specific disability or impairment: 3. Explain how the applicant’s disability or impairment substantially limits one or more major life activities (activities most people are able to do), and does the applicant use a mobility device: 4. What special facilities, special planning or design does the applicant use to utilize RTA’s buses, facilities (such as hubs or schedules) and services? In other words, what accommodations does the applicant require to independently use public transportation? Page 2 of 3
MENTAL DISABILITIES Part 4 – These four questions must be answered completely Complete this section if the applicant has mental disabilities or impairments: A mental impairment is defined by the ADA as: “[A]ny mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional illness, and specific learning disabilities.” 1. What is the applicant’s specific disability or impairment: 2. Describe the applicant’s specific disability or impairment: 3. Explain how the applicant’s disability or impairment substantially limits one or more major life activities (activities most people are able to do): 4. What special facilities, special planning or design does the applicant use to utilize RTA’s buses, facilities (such as hubs or schedules) and services? In other words, what accommodations does the applicant require to independently use public transportation? Page 3 of 3