Connections Program Application

Name: ______________________________________________________________________________

Last First Date of Birth

Address:_____________________________________________________________________________

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 myaccessride.com

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

(optional):

___________________________________________________________________________________

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 ada@accesstransys.com.