Application for CityLift Paratransit Services

Please note: At the end of this form you must submit a statement from your physician on their prescription pad or official letterhead stating your disability or disabilities, which make you unable to use the fixed route and in their professional opinion believe you are eligible for CityLift services AND your downloaded and completed medical professional section will need to be attached. If you have trouble viewing both pages of the document, please make sure to download the document instead of viewing in your browser.

Download Medical Professional Questionnaire

Rider Information

Name*

Prefix First Middle Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (daytime)*

Phone (evening)*

Date of Birth*

Who do you reside with?*

In Case of Emergency Notify (List supported Living Contact, if applicable)

Emergency Contact Name

First Last

Emergency Contact Phone

Relation to applicant

Signatures

Signature of Applicant*

Signature of person other than applicant*

Medical Questionnair & Physician Statement

Medical Professional Questionnaire & Physician Statement*

Please upload your Medical Professional Section and physician statement. Download Medical Professional Questionnaire

Please note: The CityLink Mobility Management Department must receive a statement from your physician on their prescription pad or official letterhead stating your disability or disabilities, which make you unable to use the fixed route and in their professional opinion believe you are eligible for CityLift services AND your downloaded and completed medical professional section will need to be attached. If you have trouble viewing both pages of the document, please make sure to download the document instead of viewing in your browser.

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 50 MB.

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Rider Information

In Case of Emergency Notify (List supported Living Contact, if applicable)

Please answer the following questions:

If you use a Wheelchair or Scooter:

Signatures

Medical Questionnair & Physician Statement