Forms • Battle Creek, MI • CivicEngage

1. Name:*

2. Address:

City:

State

Zip:

3. Phone (Home):

Phone(Other):

4. E-mail:

5. Date of Birth:

6. What is the disability which prevents you from using Battle Creek Transit’s fixed route bus services:

Is this condition temporary?

If yes, expected duration until:

7. How does this disability prevent you from using route services? Please explain completely.

8. Are there any other effects of your disability of which we need to be aware?

The following information will be used to ensure that an appropriate vehicle is utilized to provide your
transportation and that an accurate analysis of your request can be made by Battle Creek Transit.

9. Do you use any of the following aids to mobility? (Check all that apply)

	Wheelchair
	Guide Dog
	Powered Scooter
	Personal Care Attendant

	Cane
	Crutches
	Walker
	Other

Other Aid:

10. Can you travel 200 feet without the assistance of another person?

	Yes
	No

Sometimes

11. Can you travel ¼ mile without the assistance of another person?

	Yes
	No

Sometimes

12. Can you travel ¾ mile without the assistance of another person?

	Yes
	No

Sometimes

13. Can you climb three 12-inch steps without assistance?

	Yes
	No

Sometimes

14. Can you wait outside without support for 10 minutes?

	Yes
	No

Sometimes

15. Is your ability to travel out-of-doors affected by snow or ice?

	Yes
	No

Sometimes

15. Is your ability to travel out-of-doors affected by snow or ice?

	Yes
	No

Sometimes

16. Is your ability to travel or wait out-of-doors affected by extremes of hot or cold weather?

	Yes
	No

Sometimes

17. I hereby certify that the information given above is correct.

Type Full Name:

Date:

* indicates required fields.

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