2. Applicant's First and Last Name
4. I authorize the release of medical information to the City of Port Arthur Transit to complete the application process for ADA Paratransit Services.
6. Signature of Applicant or Applicant's Representative
7. Date
   Date
9. Physician's Name
10. Phone Number
12. Address
14. City
15. State
16. Zip Code
18. To be Completed by The Physician
20. Describe the nature of the applicant's disability
22. What is their current treatment program?
24. Is this disability

    Select one

    1. Long-term
    2. Short-term
25. Does the applicant require a personal care attendant?

    1. Yes
    2. No
26. Please explain
28. What is the prognosis of the applicant's disability?
30. Does the applicant have any restrictions?

    1. Yes
    2. No
31. If yes, please explain
33. I am familiar with the disability of the above named individual and am authorized to provide information to the City of Port Arthur Transit as required to complete the ADA Paratransit Services application. I certify the aforementioned information is true and correct.
    Physician's Signature
34. Date
    Date
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37. Print Only

* indicates a required field