Access Sangamon Overview and Application

First Name

Last Name

Address

City

State

Zip

Phone (Day)

Phone (Evening)

Tell Us About Your Needs

What disability prevents you from using the SMTD fixed line buses?

Is your medical condition and/or disability temporary?

If yes, what is the expected duration?

Does your disability prevent you from getting to and from a bus stop?

If yes, please explain.

How far can you walk without assistance?

Can you recognize your destination?

If no, please explain.

Do you have difficulty receiving verbal or written directions?

If yes, please explain.

Is there a physical barrier that combines with your disability that prevents travel to and from the bus stop?

Yes
No
Sometimes

If yes or sometimes, please explain.

Transportation Needs

Have you ever received SMTD bus training or mobility training?

Do you require assistance when traveling? If yes, check all that apply.

An "A" will be added to your ADA number if you have checked items for which no service can be provided by the driver and you will be required to have someone help you.

The Access Sangamon staff will monitor passengers´ abilities as they ride Access Sangamon. If at anytime it is determined through these observations that the rider needs additional assistance to be able to safely use the service, the rider will be notified by Sangamon Mass Transit District that an "A" is being added to their eligibility number. The rider must make arrangements for the assistance that is necessary or ridership will be denied. Access Sangamon will not transport individuals who cannot be transported safely.

The rider may appeal this decision in writing to Appeal Access Sangamon, Sangamon Mass Transit District, 928 South Ninth Street, Springfield, Illinois, 62703

Choose all that apply

Assistance from your door to the bus
Assistance from the bus to the door
Assistance boarding and deboarding
Assistance with packages
Assistance with mobility devices

If you need any other type of assistance not listed above, please explain here.

Emergency Contact

Name

Title

Address

City

State

Zip

Phone

Nice try spambot

Overview and Application

Access Sangamon Application

Tell Us About Your Needs

Transportation Needs

Emergency Contact

Follow Us on Social