Application For Riverside Transit Agency Disabled Identification Card (Page 2 of 2) in pdf

PLEASE CHECK WHICH OF THE REQUIREMENTS BELOW MEET YOUR ELIGIBILITY CRITERIA:

___ Visual Impairment - low vision, partially sighted, legally blind, total blind

___ Hearing Impairment - total deafness, 50% bilateral hearing loss uncorrected by use of a hearing aid

___ Musculoskeletal Impairments- arthritis, osteoarthritis, muscular dystrophy, fibromyalgia, degenerative joint

disease

___ Cardiovascular impairment - heart disease, congestive heart failure, peripheral vascular disease

___ Respiratory impairment - asthma, COPD, emphysema, chronic bronchitis

___ Amputation of or anatomical deformity (due to vascular of neurological deficits, traumatic loss of muscle

mass or tendons), or instability of hands, foot, one lower extremity or above torsal region

___ Neurological disorder- cerebral palsy, multiple sclerosis, Parkinson’s disease, neuropathy, paralysis,

chronic fatigue

___ Paralysis, incoordination or functional motor deficit in any limbs due to brain, spinal or peripheral nerve

injury

___ Intellectual disability, including learning disability, autism, and psychosis disorders either to the extent that

applicant is living in a board and care facility, or at home under supervision

___ Seizure disorder - Epilepsy involving impairments of consciousness, which occur more than once a month

___ Any other disability you consider will restrict mobility. Please detail below or attach an explanation to

application: ____________________________________________________________

LICENSED HEALTH CARE PROFESSIONAL CERTIFICATION:

In my professional judgment this applicant’s disability is:

(Check one only) ____ Permanently Disabled ____ Temporarily Disabled For ____ Months

Note: Identification cards will not be issued for less than 3 months or more than 3 years.

Name: (Please Print) _____________________________________________________ Date: ____/____/____

Address: _______________________________ City: _________________ State: _____ Zip Code: _______

Telephone: ( ) _____- ______ California Professional License Number: _________________________

I understand that failure to certify disabilities in accordance with the above guidelines will result in cancellation

of my certification privileges. I hereby declare under penalty of perjury that the information provided is true

and correct.

License Health Care Professional (Signature): ___________________________________________________

SPECIAL EDUCATION PROGRAM:

Special Education Programs: A student currently enrolled in an elementary, junior/middle or senior high school

that is permanently disabled and is receiving services of a Special Education Program.

A Special Education Coordinator may certify a student enrolled in a Special Education Program.

Name of School: __________________________________ Address: ________________________________

Name of Special Education Coordinator: ____________________________________ Date: ___/____/____

Signature, Special Education Coordinator: ____________________________________________________

Effective January 16, 2013

Application For Riverside Transit Agency Disabled Identification Card Page 2