= Please print all information clearly. Thank you. Section 1: Passenger Information Name: Home Addiess: Name of Building or Complex if applicable) Apartment number: City: Tip: ___ bate of Binh: Home Phone: Cell Phone: ion 2: Please. 5 that. a 1. 1use mobility aids ] Manual Wheelchair ___Blecttic Wheelchair _——Amigo/Power Scooter ___Cane Walker — Crutches Guide Dog Personal Wheeled Cart 2. __ Ineed to travel with staff while on the tus. 3. ___ Ihove a vision impaiment 4. __ Ihave a hearing impoirment 5. ___ Iiravel with oxygen | 6. Any other information that DATA needs to be aware of; Continued on next pageyergenc Inform List the names of wo people and/or agency {if appropriate] which may | be contacted in case of an emergency: Contact Name #1 Phone Alternate Phone | aes Relationship: _ BREE REeE eee ere Eee Eee Ee ContactNome #2 | Phone _temate Phore Address Relationship: ee 1_ADA Ve ~ Any possenger (other than serior citizens) who is eligible forthe reduced fare under the Americans with Disabiies Act (ADA) needs fo have a medical doctor or mental heaith professional ‘complete this section, EEE Jattest thot (name) is eligible for the reduced fare based on thelr ADA quailications. | sianature: | Name of Professional: Ageney (it applicable): city State Phone Number: Reminder: A separate form must be completed for each family member, Return your completed application to: Delta Area Transit Authority 2901 27 Avenue North Escanaba, Mi 49829