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METROLift Application

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Step 1 of 4: Submit Physician or Health Care Professional's Certification Form

To apply for METROLift service, submit a Physician or Health Care Professional's Certification Form completed and certified by a physician / certified health professional who is familiar with your disability. 

Download PDF of Physician or Health Care Professional's Certification Form >


NOTE: If you prefer to submit the application in person or fax or mail, here is a print friendly PDF version that can be filled out by hand.

Step 2 of 4: Complete the Applicant Information Form

Have you ever applied for METROLift?*
Mailing Address (if different from the home address):

Emergency Contact Information:

Step 3 of 4: Complete the Individual and Mobility Information Form

What assistive device(s) do you use when traveling? (Please check all that apply.)*
Can you walk or use your wheelchair or assistive device(s) from your home to the nearest street intersection without assistance?*
Can you find your way to a bus stop without getting lost?*
How long can you stand and wait for a bus?*
All buses have a "destination sign" in front that shows the route name and number. Can you read a bus destination sign?*
Can you ask the driver where the bus is going?*
Can you give or write a note to the driver?*
Can you understand the driver's answer?*
If you were on the bus or train, could you pay the fare by putting money in the fare box, or by tapping the METRO Q Card on the Q box?*
If you were on the bus or train, could you recognize the place where you wanted to get off the bus or train?*
Have you ever received orientation and mobility training or travel training?*
Do you require someone to travel with you?*
Can you wait alone or independently at your residence and places to which you travel?*

Step 4 of 4: Agreement and Authorization

I state that the information I have provided is true and accurate.

I authorize the release of diagnostic and functional information as requested in Step 1 to METRO for the sole purpose of making a determination regarding my eligibility for paratransit service (METROLift) and understand that personal and medical information will be kept confidential.

I understand that intentionally providing false or misleading information or refusal to undergo an in-person interview assessment is grounds for denial of METROLift services. If approved, I agree to follow the rules and guidelines established by METROLift and to promptly inform METROLift of any changes in my residence, phone number and, if applicable, my representative's name and phone number; and any significant change in my condition that would affect my level of mobility. I understand that failure to follow proper procedures or cooperate with METROLift staff, demonstrating illegal or disruptive behavior or, if my condition at any time poses a direct threat to the health or safety of others, such situations may result in either suspension and/or termination of service.

Agreement

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