Metro 
ADA PARATRANSIT APPLICATION 
 
In accordance with the Americans with Disabilities Act of 1990 (ADA), Metro and St. Clair Transit District provide “paratransit” (van/shared-ride) services to individuals with disabilities who are unable to use the fixed route services (i.e. buses - MetroBus or light-rail-MetroLink).  Individuals served do not have to reside in the area, but they must be traveling within an area served by MetroBus or MetroLink. The purpose of this application is to provide an opportunity for you to describe barriers in the environment and limitations that you may have which prevent you from using available fixed route services.  The information that you provide will help the transit agencies to understand your abilities and travel challenges.  All information contained in this application will be kept confidential and shared only with the professionals involved in evaluating your eligibility. 
 
All applicants, whether new or individuals applying for recertification, must complete a new application and provide written professional verification of disability.  The ADA certification process will include a personal functional assessment to determine if and under what conditions, you can use fixed route services. The evaluation focuses on your abilities and will be performed at no cost to you.  Free transportation to and from the evaluation site will be provided upon request. 
 
All questions must be answered.  Incomplete forms will be returned.  If you have any questions or need assistance completing this form, please call (314) 982-1510.  To request the form in an alternative format, please contact Amy Parker, ADA Coordinator, at (314) 982-1525 or adadirector@metrostlouis.org.  
 
 Metro’s ADA Paratransit Eligibility process includes: 
 
1.  Receipt of completed application including professional verification of disability. 

2.  An in person functional assessment of transit-related skills. In a few instances, the functional assessment may require the evaluation of skills by orientation and mobility specialists or travel training specialists. If this is necessary, the applicant will receive up to 90 days of temporary eligibility for this type of assessment to occur. 

3.  Metro will schedule your assessment to occur within 3 to 10 days and notify you of the eligibility determination all within 21 days following the receipt of your completed application.  If you have not heard from our offices after 21 days, you will be granted Presumptive Eligibility if Metro caused the delay in processing your application.  Presumptive Eligibility will permit you to use Call-A-Ride or ATS services until a final determination has been made regarding your ADA eligibility for these services.  If Metro did not cause the delay, you will not be granted presumptive eligibility, but you can expect an eligibility decision within 3 to 10 days following your assessment.  You may call (314) 982-1510 to learn more about presumptive eligibility. 

Please return this completed application including written professional verification of disability.
MAIL:  Metro, One Metropolitan Square, 211 N. Broadway-Suite 700, St. Louis, MO 63102 
FAX: (314) 335-3419 or EMAIL: adaservices@metrostlouis.org
Please call Metro Staff at  (314) 982-1523  seven days after mailing or two days after sending electronically to schedule your assessment appointment.
Please keep this page for future reference & see the reverse side for tips to help avoid processing delays as well as information about transportation to the assessment. 
TO AVOID ANY PROCESSING DELAY 
 
Applicant:  Metro is committed to processing your application in a timely manner, but we need your help.  Please ensure that all parts of the application and attachments are completed before submittal to Metro. Please tell us about all disabilities that you have. Please note that written professional verification of disability is required and must be submitted with the application.    This professional verification must be completed by a professional who is familiar with your disability such as a doctor, social worker, counselor, independent living specialist, teacher, orientation & mobility specialist, etc…   There is a professional verification form included with the application that may be used for this purpose or a letter may be submitted on professional letterhead.   
 
Applications that are incomplete or lack adequate professional verification of disability cannot be processed.  Thank you in advance for your cooperation in submitting all of the required information. 
 
Metro will offer you an assessment appointment scheduled approximately 3 to 10 days after the receipt of your completed application.  Please accept an appointment offered within this timeframe to ensure a timely eligibility determination. 
 
TRANSPORTATION 
 
Upon request, transportation to and/or from the assessment appointment will be arranged and provided to you at no cost.  You may verify that transportation 
has been arranged and obtain your pick up time by calling Metro 
Call-A-Ride’s Customer Assistance line at 314.289.5230 (Missouri residents) or Alternative Transportation Service – ATS at 618.239.0749 (Illinois residents).  If you are unable to keep your assessment appointment, 
please call the appropriate number to cancel your rides and then 
contact Metro’s ADA Services’ Appointment Scheduling line at 314.982.1523 to reschedule your assessment appointment.
GENERAL INFORMATION 

Last Name: __________________________________________________________________ 
 
First Name: _______________________________________________ MI: _______________ 
 
Address: ________________________________________________ Apt#: _______________ 
 
City: ____________________________ State: _________ Zip: _______________ 
 
Cell Phone: (____) ______________________________ TTY:  ❒Yes  ❒ No 
 
Home Phone: (____) ______________________________ TTY:  ❒Yes  ❒ No 
 
Birth Date: _______/________/________    Gender:  ❒Male   ❒Female ❒Non-Binary
 
Social Security Number:  ____________--_________ -- ____________ 
 
Current or previous Call-A-Ride ID card# ______________Expires (ed)________ 
 
Do you NEED future written information provided to you in an accessible format? (Note, if you choose email, ALL written correspondence will be sent by this method.)   
 	Yes ❒   No ❒   If YES:  Please indicate your preferred format: 
❒Email_________________________________       ❒Braille         ❒Large Print  
 	❒ Other (Specify)_________________________________       
Emergency Contact Person: 
 
Name:  _________________________________ Relationship: ____________________ 
 
Day Phone: (____) ___________________ Eve. Phone: (____) ____________________  

Did anyone assist you with completing this form?  ❒Yes    ❒No 
 
If yes, please provide the following information about that person. 
 
Name____________________________________________________________ 
 
Phone: (____) ___________________ Relationship: ______________________ 
APPLICANT’S CERTIFICATION 
 
Please Complete Section A UNLESS you are a minor or have a legal guardian.  If you are a minor or have a legal guardian, your parent or guardian must complete Section B. 
 
A.  I understand that the purpose of this application is to determine if there are times that I cannot use fixed route services and am eligible to use the shared ride services of Metro CALL-A-RIDE or ATS.  I certify that the information provided in this application is accurate and I understand that I must complete a functional assessment of my abilities.  
 
Signature: _______________________________________ Date: _____________ 
 
B. I understand that the purpose of this application is to determine if there are times that the applicant cannot use fixed route services and is eligible to use the shared ride services of Metro CALL-A-RIDE or ATS.  I certify that the information provided in this application is accurate and I understand that the applicant must complete a functional assessment of his or her abilities.  
 
I consent to the Applicant’s interview and functional assessment of his or her travel abilities and limitations to determine ADA Paratransit service eligibility.  I understand that the Applicant must be present for the interview and functional assessment.  I understand that if the applicant travels to the assessment on ATS or Call-A-Ride, he or she will not be supervised by the driver or assessment office staff.  He or she may transfer from one Call-A-Ride van to another on his or her trip.  If these issues cause concern, he or she may bring an attendant at no charge.  I understand that I may be present with the Applicant during the interview and any functional assessment, and state that: 
 ❒I will be present, 
❒I designate ____________________________to be present on my behalf, or 
❒I waive my right to be present and do not designate another person to be present               on my behalf. 
 
Signature: _______________________________________ Date: ____________ 
Relationship to applicant:____________________________________________ 

INFORMATION ABOUT YOUR DISABILITY AND MOBILITY EQUIPMENT 
 
1.	What type or types of disabilities prevent you from using MetroBus or MetroLink? 
Please check all that apply. 
 
❒ Physical disability   		❒ Visual impairment/Blindness 
 
❒ Developmental disability  	❒ Brain injury 
 
❒ Mental illness    		❒ Other ____________________________________ 
 
2. Please describe your disability/disabilities in more detail, including the diagnosis/diagnoses.   
__________________________________________________________________________ 
 
__________________________________________________________________________ 
 
__________________________________________________________________________ 
 
3. Please indicate all of the mobility aids or equipment you use when traveling outside your home. 
 
 ❒Communications Device  	❒Long white Cane 
 ❒Cane     				❒Manual Wheelchair 
 ❒Powered Wheelchair   	❒Scooter 
 ❒Crutches     			❒Walker 
 ❒Leg braces     			❒Prosthesis 
 ❒Service Animal    		❒None 
 ❒Other:  ______________________________________________ 
 
4. If you use a wheelchair or scooter, is it: 
  30 Inches Wide or Less?    			❒Yes    ❒No  	❒Not Sure
  48 Inches Long or Less?   			❒Yes    ❒No  	❒Not Sure
  600 Pounds or Less when Occupied?   	❒Yes ❒No ❒Not Sure

 
 
INFORMATION ABOUT YOUR CURRENT USE OF FIXED ROUTE  
SERVICES OR PARATRANSIT SERVICES 
 
1. How often do you currently use MetroBus or MetroLink services by yourself?  

❒Daily ❒Several times per week  ❒ At least monthly 
❒Rarely ❒Never 
 
2. Do you or will you need the assistance of another person to travel while using Call-A-Ride? 

❒Yes  ❒No  ❒Sometimes 
 
     3. If you do not currently use MetroBus or MetroLink, please check all that apply: 
❒The closest stop is too far from my house. 
❒ I do not know how to ride the bus or MetroLink. 
❒ I cannot travel by myself between the bus stop and my destination. 
❒ I’m afraid to use the bus or MetroLink. 
❒ I do not want to use the bus or MetroLink. 
❒ Other ___________________________________________________________. 
 
4. Please list destinations for which you use or need Call-A-Ride or ATS services. 
 
a. Address: _________________________________________________________________________ 
_________________________________________________________________________ 
b. Address:  
____________________________________________________________________________________________________________________________________________________ 
c. Address:  
____________________________________________________________________________________________________________________________________________________ 
 
5. I can cross streets independently under the following conditions: (check all that apply) 
a. At quiet streets with very little traffic  	❒Usually ❒Sometimes ❒Never 
b. At most traffic lights   		         	❒Usually ❒Sometimes ❒Never 
c. I can ALWAYS cross independently 	❒Yes ❒No 
d. I can NEVER cross independently	❒Yes ❒No 
6. 	Please read the following statements and check all those that best describe your ability to use Metro services by yourself.   
❒ I use MetroBus or MetroLink for some trips, but sometimes there are barriers that prevent me from using these services. 
❒ I use the bus or train frequently, on routes to familiar destinations. 
❒ I use the bus or train to go to new places. 
❒ I believe I could use the bus or train if someone taught me. 
❒ I am not able to use the bus or train by myself. 
❒ The severity of my disability changes from day to day. I ride the bus or train when I am 
   	feeling well. 
❒ I can get to and from the bus stop if the distance is not too great. 

YOUR FUNCTIONAL ABILITY 
 
Your answers to questions in this section will help us better understand your functional ability in specific areas.  For each question, please circle only one answer.  Your answers should be based on your physical and mental ability to perform the tasks.  Assume that you are using the mobility equipment that you usually use when traveling outside your home. 
 
Without the help of someone else, can you: 
 
1. Use the telephone to get information? 

Always   Sometimes  Never  Not Sure 
 
2. Travel one level block on the sidewalk in good weather? 

Always   Sometimes  Never  Not Sure 
 
3. If you are able to do this, how long does it take you? 

Less than five minutes  Five to ten minutes  Not Sure 
 
4. Cross the street, if there are curb cuts? 

Always   Sometimes  Never  Not Sure

5. Travel three blocks on the sidewalk in good weather?

Always   Sometimes  Never  Not Sure 
6. If you are able to do this, how long does it take you? 

Less than ten minutes Ten to Fifteen minutes    Not Sure 

7.  Step on and off a curb from a sidewalk? 

Always   Sometimes  Never  Not Sure 
 
8. Wait ten minutes outside in good weather if there is no seat? 

Always   Sometimes  Never  Not Sure 
 
9. Find your own way to or from transit stop after being shown? 

Always   Sometimes  Never  Not Sure 
 
10. Currently travel by yourself using any mode of transportation? 

Always   Sometimes  Never  Not Sure 
 
11. If always or sometimes, which modes of transportation allow you to travel independently? 

Call-A-Ride / ACT / ATS      MetroBus / MetroLink  Car 
 
12. If the weather is good and there are no environmental barriers, how far can you travel outside independently, using your mobility device if applicable? 
 ❒ I cannot travel outdoors alone at all ❒Curb in front of my house
  ❒1 block    ❒3 blocks    	❒6 blocks 		❒9 blocks     	
  ❒More than 9 blocks 	❒Not sure     	❒Other:_______________________ 
Please use this space to tell us anything else you would like us to know about your travel challenges and your ability to use buses and or MetroLink. 
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
TO AVOID ANY DELAY WITH PROCESSING YOUR APPLICATION: Please review this form to make sure that you have completed all of the questions to the best of your ability. Be sure to sign the application. Return the application by mail to: METRO, One Metropolitan Square 211 N. Broadway – 
Suite 700 St. Louis MO 63102, by email to adaservices@metrostlouis.org or by fax to (314) 335.3419.  
Professional Verification
Page 1 of 2 
Dear Professional: 
 
You are being asked by _____________________________(applicant) DOB: _____________ 
SS# (last 4 digits): ______________to provide information regarding his/her ability to use our transit system.  Federal law requires that Metro (Call-A-Ride / ATS) provide Paratransit services to persons who cannot use 
fixed-route transit services.  The information you provide about the noted disability or disabilities will allow us
 to evaluate this request and its application to specific trip requests.  This does not include persons who find 
it uncomfortable or difficult to get to and from bus stops or rail stations. 
 
To qualify for ADA Paratransit services, a person must be unable to use regular fixed-route transit due to a physical or mental disability.  Indicate below, the nature of the applicant’s disability. 
 
For all applicants--Please specify the disability/disabilities of the applicant.   
Please include DSM-V or ICD 10 codes, if available.  
 
________________________________________________________________________________ 
 
________________________________________________________________________________ 
 
DSM-V and/or ICD-10 Codes:_________________________________________________________ 
 
For applicants with seizure disorder— 
 
Date of onset:___/___/___ 
 
Type of seizures:__________________________________ 
 
Frequency of seizures:______________________________ 
 
Date of last seizure (if known):___/___/___ 
 
An indication of the effectiveness of the medication(s) in controlling seizures:____________________ 
 
________________________________________________________________________________ 
 
Presence/Absence of aura:__________________________________________________________ 
 
For applicants who have had a stroke— 
 
American Heart Association Stroke Outcome Classification:_________ 
 
For applicants with blindness or low vision— 
 
Best Corrected Vision:  ___/___ OS ___/___OD  Visual Field: ______degrees 
 
Professional Verification Page 2 of 2 
For applicants who have a cardiac condition— 
 
American Heart Association Classification:_________________ 
Precautions regarding activity:_______________________________________________________ 
 
Precautions regarding extreme heat and cold (in terms of activity level as well as tolerance to 
 
sitting/waiting):_____________________________________________________________________ 
 
________________________________________________________________________________ 
 
For all applicants--Please describe how the applicant’s disability prevents him or her from using MetroBus or MetroLink.   
________________________________________________________________________________ 
 
________________________________________________________________________________ 
 
For all applicants--Please list any activity or environmental precautions:  
 
________________________________________________________________________________ 
 
________________________________________________________________________________ 
 
The disability is _____ Permanent or_____Temporary.  
If the disability is temporary, expected duration is_______ months. 
 
 Your professional area of specialization is, check one:  
  
❒Audiologist    			❒Registered Nurse/Licensed Practical Nurse  
 	❒Rehabilitation Specialist  		❒Physical/Occupational/Speech Therapist  
❒Physician    			❒Independent Living Specialist  
❒Optometrist   			❒Psychologist   
❒Physician Assistant		❒Case Manager  
❒Social Worker   			❒Other:_______________________________________   
     	❒Orientation & Mobility Specialist
   
Your Name/Title:  _______________________________________________________________ 
Agency/Company Name:  _________________________________________________________
Professional License # (if applicable): _________________________________________________ 
Office Address:  _________________________________________________________________ 
Office Phone #:  (______) ________ -- _____________Fax:  (______)________  --__________ 
I hereby certify that the above information is true.  Metro (1) may verify the validity of the professional providing the certification, (2) make the final determination on an applicant’s eligibility for ADA Paratransit Service. 
 
____________________________________________ 	________________________ 
Signature       							Date
METRO, One Metropolitan Square 211 N. Broadway – Suite 700 St. Louis MO 63102 or fax to (314) 335.3419
adaservices@metrostlouis.org