Connections Program Application
Name: ______________________________________________________________________________
Last First Date of Birth
City_______________________________________ State____________ Zip_________________
Phone: Home _________________________ Work_________________________________
Cell_____________________ E-mail address_______________________________
Information about your disability
What is your disability?_______________________________________________________________
How does your disability limit you? Check all that apply:
______ Walking _____ Seeing ________ Communicating
______ Understanding ______ Hearing ________ Problem solving
Is your disability permanent? _____Yes _____No
If no what is the expected duration? ___________________________________________________
Do you use any mobility aids? _______No ______ Yes (If yes, check all that apply):
_____Manual wheelchair _______ Scooter _____White Cane
_____Motorized wheelchair _______Crutches _____ Service animal
_____Walker or rollator _______Portable oxygen _____ Other _______________
Check the documentation you are submitting with the application:
Verification of disability (including diagnosis) from:
_____Health care provider ______ School district (IEP) *must include signature page
_____Agency from which you receive disability related services
Proof of Age (Documents must be valid and not expired):
_____ Driver’s license _____ Birth Certificate ______ Military Discharge
_____ PA Photo ID _____ PACE Card ______ Social Security Verification
_____ Passport _____VA Universal ID ______ Immigration or Resident Alien Papers
Questions? Call
(412) 562-5353 or TTY 711
Office hours are Monday
Friday 8 a.m.4:30 p.m.
Find ACCESS information
online at
Revised January 2021 Page 2 of 2
I am currently eligible for Medical Assistance or Community Health Choices (check one)
_____ Yes _______ No _______ Not Sure
Pittsburgh Regional Transit Bus Service You Will Use
Which Pittsburgh Regional Transit routes serve your neighborhood? ______________________
Where is the bus stop closest to your home? _________________________________________
Why do you need ACCESS Connections Service? (Check as many as apply)
_____ The bus stop is more than ¾ mile from my home
_____ The bus stop is more than ¾ mile from my destination
_____ There is no bus service at the time I need to travel
_____ I have to take several buses, which takes me a long time
Trips you will take
Please list the three most common trips you would like to take.
Origin (Address) Destination (Address) Frequency
Emergency Contact
Please provide the name and phone number for someone we should contact in case of an emergency
Will you need future materials in an accessible format? (Circle):
Large Print Word or Text file by e-mail Braille
Signature (Required)
I certify that I have been truthful and that the information I have provided is accurate and correct.
_______________________________________________ ___________________________________
Signature Date
Submit your completed application along with proof of age and verification of your disability. Mail to ACCESS
Connections Program, 650 Smithfield St., Pittsburgh, PA 15222 or e-mail to