Wheelchair Form

April 1, 2010

In an effort to better facilitate the transportation of our physically challenged passengers, we require all passengers who board via the wheelchair lift to fill out this form. The information is designed to aid us in determining which bus would be appropriate for the requested transportation.

A couple of items to remember prior to boarding our buses:

Do not have items hanging from the back of the chair which will impede the maneuvering of the wheelchair.
Have the exact fare ready prior to boarding the bus. The driver can not make change and payment is required prior to boarding.
Please be waiting at the curb for the bus. If you miss the bus we cannot send the bus back and you will be required to pay the one-way fare before your next trip. This is our "No Show" policy.

Passenger:
Name
Address
City
Phone
Emergency contact:
Name
Phone
Dimensions
Combined weight of passenger and manual/electric wheelchair or scooter:
Weight in pounds
Actual width/length of wheelchair outside dimensions:
Width in inches
Length in inches
Additional information:
Are you able to transfer to a regular bus seat?
Yes	No
Does an aide accompany you? (Aides must assist passengers using wheelchairs.)
Yes	No

If you have any questions, please feel free to call our office.

Sincerely,

Robert DiBella
Director of Public Transit

Passenger:

Emergency contact:

Dimensions

Additional information:

Ulster County Home Page