Access Sangamon Application


Federal law requires that the Sangamon Mass Transit District provide Paratransit (hereafter referred to as Access Sangamon) services to persons who cannot use available fixed route services. The information provided will allow us to make an appropriate evaluation of this request. Thank you for your cooperation in this matter.

If you are printing this form to be filled in, please mail it to:

SMTD

928 South 9th Street

Springfield, IL 62703

Note: An asterisk (*) indicates a required field.

Name *
Name
Phone (Day) *
Phone (Day)
Phone (Evening)
Phone (Evening)
Describe how the medical condition or disability impacts you on a daily basis.
Is your medical condition and/or disability temporary? *
(If your condition is temporary your application will be reviewed every six months)
Does your disability prevent you from getting to and from a bus stop? *
Can you recognize your destination? *
Do you have difficulty in receiving verbal or written directions? *
Is there a physical barrier that combines with your disability that prevents travel to and from the bus stop? *
(Example: Stairs, No Sidewalks, No curb cuts, Heat, Cold, Ice, Snow, etc.)
Transportation Needs
Have you ever received SMTD bus training or mobility training?
Do you require assistance when traveling? If yes, check all that apply.
An "A" will be added to your ADA number if you have checked items for which no service can be provided by the driver and you will be required to have someone help you. The Access Sangamon staff will monitor passengers´ abilities as they ride Access Sangamon. If at anytime it is determined through these observations that the rider needs additional assistance to be able to safely use the service, the rider will be notified by Sangamon Mass Transit District that an "A" is being added to their eligibility number. The rider must make arrangements for the assistance that is necessary or ridership will be denied. Access Sangamon will not transport individuals who cannot be transported safely. The rider may appeal this decision in writing to Appeal Access Sangamon, Sangamon Mass Transit District, 928 South Ninth Street, Springfield, Illinois, 62703.
Emergency contact
Phone
Phone