5081 Fred Wilson El Paso, TX 79906
Please have your Doctor or a certified Sun Metro LIFT representative complete and sign this form.
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Dear Doctor/LIFT Representative:
Sun Metro LIFT provides door-to-door transportation service on a share-ride basis using small buses equipped with hydraulic wheelchair lifts. This service is available to persons who because of their disability, are prevented from:
Independently getting to/from a bus stop or transfer point using traditional Sun Metro fixed-route buses
Independently boarding, riding and exiting a Sun Metro fixed-route bus
Boarding or getting to/from a bus stop because of the inability of the bus to deploy the lift or ramp at an inaccessible bus stop
The above applicant is applying for Sun Metro LIFT services and is kindly requesting information regarding their disability. This information will allow Sun Metro LIFT to properly evaluate the applicant’s inability to ride Sun Metro’s traditional fixed-route system and thereby becoming eligible for Sun Metro’s paratransit system.
Thank you for your cooperation.
Is the condition temporary?
If the applicant has a disability affecting mobility, is the applicant able to travel without assistance?
Is the applicant able to travel up to ¼ of a mile without assistance or equivalent to 4 blocks?
Is the applicant able to wait outside for 10 minutes without assistance or support?
Does the applicant use a mobility device? Please mark all that apply:
Does the applicant have a visual impairment? (e.g. Peripheral vision, Macular Degeneration, Cataracts etc.)
If yes, please complete the applicant’s visual acuity:
If the applicant has a visual impairment, is the applicant able to travel after dark independently?
Does the applicant have a hearing impairment?
Does the applicant have a cognitive impairment?
If the applicant has a cognitive impairment, can the applicant provide general information upon request? (i.e., telephone number, address, name)
Can the applicant deal with unexpected situations in daily routine?
Can the applicant ask for, understand and follow directions?
Can the applicant safely and effectively travel in a crowded area?
Does the applicant take any medications?
If yes, does the medication cause any side effects that would impact the applicant’s functional ability?
Should we have further questions regarding the applicant most limiting functional ability, do you authorize Sun Metro LIFT reach out to you for further questions?
Important: Sun Metro LIFT will only use this information to determine the applicant’s eligibility to use Sun Metro LIFT. Sun Metro LIFT will keep this information confidential and secure and will only use it for transportation-related purposes.
Certified LIFT Personnel or Physicians Name:
Applicant's Doctor or LIFT Representative's Signature