DEPARTMENT
OF PUBLIC WORKS
AND
TRANSPORTATION
| |
| DEPARTMENT
OF PUBLIC WORKS |
| AND
TRANSPORTATION |
|
CALL
'N RIDE
|
|
P.O.BOX
8465
|
|
GAITHERSBURG,
MD. 20898
|
|
TELEPHONE:
301-948-5409
|
|
CALL
'N RIDE PHYSICAL DISABILITY ATTACHMENT
|
| Call 'N Ride is a transportation assistance program for persons age 67 and over, those persons who are mentally disabled or those persons with physical disabilities that render them unable to use existing public transportation. |
| Please complete this form to determine eligibility for the program. |
| NAME OF PATIENT: __________________________________________________________________________________ |
| DIAGNOSIS: ________________________________________________________________________________________ |
| NATURE OF DISABILITY: ______________________________________________________________________________ |
| ___________________________________________________________________________________________________ |
| ___________________________________________________________________________________________________ |
| HOW DOES DISABILITY PREVENT THE USE OF BUS TRANSPORTATION:______________________________________________ |
| ___________________________________________________________________________________________________ |
| ________________________________________ DATE |
______________________________________________________ SIGNATURE OF PHYSICIAN |
| ________________________________________ LICENSE/CERTIFICATION# |
______________________________________________________ PRINTED NAME |
| ______________________________________________________ ADDRESS |
|
| ______________________________________________________ CITY & STATE |
|
| ______________________________________________________ TELEPHONE NO. |
