Travel Training Referral | Greater Cleveland Regional Transit Authority

5/21/2012 4:43 AM

Travel Training Referral

5/21/2012
Referred by:
Customer Service Other (please specify)
Referrer's Name: Referrer's Phone: Referrer's E-mail Address:

Trainee Information:
Name:
ID # (existing ADA customers):	Phone #:
Address:
City:	State:	Zip:

Contact Person:
Parent/Legal Guardian (Full Name) Other (please specify)

Disability:
Physical	Visual Impairment/Blindness
Cognitive	Psychiatric
Other (please specify)
Please describe disability in detail:

Mobility Aids Used for Travel (check all that apply):
Manual Wheel Chair	Motorized Wheel Chair
Scooter	Cane
Crutches	Walker
White Cane	Magnifier
Portable Oxygen	Prosthesis
Leg Braces	Service Animal
No Mobility Aid	Other (please specify)

Communication Aids Used (check all that apply):
Hearing Aid	ASL Interpreter
Voice Box	Picture Board
Alphabet Board	Language Interpreter
No Communication Aid	Other (please specify)

Other Questions or Concerns:

Proof of Payment (POP)
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Travel Training
Referral Form

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