Page 1 of 10
Living Independently Facilitated by Transportation
5081 Fred Wilson
El Paso, TX 79906
915.212.LIFT (5438)
Are you currently a LIFT Passenger?
☐ Yes ☐ No
LIFT ID number: _____________________
Application for Paratransit Transportation
Sun Metro LIFT provides door-to-door transportation service on a shared-ride basis using small buses
equipped with hydraulic wheelchair lifts. This service is available to persons who because of their disability,
are prevented from:
Category 1 – Independently getting to/from a bus stop or transfer point using traditional Sun Metro fixed –
route buses.
Category 2 – Independently boarding, riding and exiting a Sun Metro fixed-route bus
Category 3 – Boarding or getting to/from a bus stop because of the inability of the bus to deploy the lift or
ramp at an inaccessible bus stop.
Please complete this application to the best of your ability, and as thoroughly as possible. If there are any
questions that you do not understand, please call Sun Metro LIFT at 915.212.LIFT (5438) for further assistance. In
order for your application to be considered complete, all questions, including the Doctors/Agency
verification form, must be answered, the application will not be processed until completed.
The purpose of the application is to provide a fair opportunity for you to describe barriers in the environment
and how your disability prevents you from using Sun Metro fixed route transportation. The more information
provided, the better Sun Metro LIFT will understand your ability and travel challenges. Information contained
in this application will be kept confidential and shared only with professionals involved in evaluation your
eligibility status to utilize Sun Metro LIFT.
Important: At times, Sun Metro LIFT may request phone interview and/or an In-Person Functional Assessment to
obtain more information regarding your application. Sun Metro LIFT will provide transportation for an In-Person
Functional Assessment to our office at 5081 Fred Wilson, Ave. During this time, you may provide any additional
information pertaining to your application that you may deem necessary.
Page 2 of 10
Living Independently Facilitated by Transportation
5081 Fred Wilson
El Paso, TX 79906
915.212.LIFT (5438)
Are you currently a LIFT Passenger?
☐ Yes ☐ No
LIFT ID number: _____________________
General Applicant Information
Please Print
1. Name: _____________________________________________________________________________
2. Address: ______________________________________ Apt: ________ Zip Code: ______________
3. Home #: ___________________________ Cell Phone #: __________________________________
Email address: ______________________________________________________________________
4. Date of Birth: _________________________________________ Gender: _____________________
5. Emergency Contact Information:
Name: _____________________________________________________________________________
Telephone #: ________________________________ Relationship: __________________________
Name: _____________________________________________________________________________
Telephone #: ________________________________ Relationship: __________________________
6. Would you prefer to receive future written information in an alternative format? Please
mark desired format.
☐
Standard Print
☐
Large Print
☐
Email address: __________________________________________
☐
Spanish Format
☐
Other: __________________________________________________
Page 3 of 10
Living Independently Facilitated by Transportation
5081 Fred Wilson
El Paso, TX 79906
915.212.LIFT (5438)
Are you currently a LIFT Passenger?
☐ Yes ☐ No
LIFT ID number: _____________________
About your Disability
7. Do you have a disability which prevents you from using the Sun Metro fixed-route? (The
fixed-route system consists of the regular Sun Metro large buses)
☐
Yes
☐
No
8. If yes, please describe any physical, cognitive, visual, or functional disabilities which
prevent you from using the Sun Metro fixed-route bus service below:
9. Is your disability or disabilities a permanent or temporary condition?
☐
Permanent
☐
Temporary
10. Do you have a visual impairment?
☐
Yes
☐
No
11. Do you have a hearing impairment?
☐
Yes
☐
No
12. Are you able to travel independently after dark?
☐
Yes
☐
No
☐
Sometimes
If you indicated ‘no’ or ‘sometimes’, please explain:
13. Are you able to independently locate an audible cross walk indicator and successfully
cross an intersection?
☐
Yes
☐
No
☐
Sometimes
If you indicated ‘no’ or ‘sometimes’, please explain:
Page 4 of 10
Living Independently Facilitated by Transportation
5081 Fred Wilson
El Paso, TX 79906
915.212.LIFT (5438)
Are you currently a LIFT Passenger?
☐ Yes ☐ No
LIFT ID number: _____________________
14. Are you able to independently navigate through a fixed route terminal and locate your
desired bus stop?
☐
Yes
☐
No
☐
Sometimes
If you indicated ‘no’ or ‘sometimes’, please explain:
15. Do you currently take any medication?
☐
Yes
☐
No
If yes, does your medication impact your ability to utilize the fixed-route system? If so,
Please explain:
16. Do weather conditions affect your disability? If so, please explain how:
17. Do you use a mobility device?
Please mark all that apply:
☐
Portable Oxygen
☐
Crutches
☐
Walker
☐
White Cane
☐
Service Animal
☐
Leg Braces
☐
Powered Wheelchair
☐
Powered Scooter
☐
Prosthesis
☐
Manual Wheelchair
☐
Walking Cane
☐
Communication Board
☐
Respirator
☐
Other, please explain:
_________________________________________
18. Do you require assistance to/from the front door of your home?
☐
Yes
☐
No
19. Do you require a Personal Care Attendant?
☐
Yes
☐
No
Page 5 of 10
Living Independently Facilitated by Transportation
5081 Fred Wilson
El Paso, TX 79906
915.212.LIFT (5438)
Are you currently a LIFT Passenger?
☐ Yes ☐ No
LIFT ID number: _____________________
Current Mode of Transportation and Navigating the Fixed-Route System
20. Are you currently able to utilize the fixed-route system?
☐
Yes
☐
No
21. If you answered ‘no’ please answer the following questions:
a. Why are you not able to use the regular fixed route buses?
b. Are there times when you would be able to use it? If so, under what
circumstances?
c. Are there any physical or environmental barriers in the fixed-route system
which prevent you from using it? (i.e., inaccessible bus, lack of curb cuts or
ramps/sidewalks, dirt, gravel, etc.)
22. Do you think with enough training that you would be able to utilize the fixed-route?
23. If you utilize the fixed-route system, how often do you utilize the service?
☐
Daily
☐
1-2 a week
☐
1 -2 a month
☐
Never utilized fixed-route
24. Are you able to independently and without assistance walk up to ¼ mile (about 4
blocks)?
☐
Yes
☐
No
Page 6 of 10
Living Independently Facilitated by Transportation
5081 Fred Wilson
El Paso, TX 79906
915.212.LIFT (5438)
Are you currently a LIFT Passenger?
☐ Yes ☐ No
LIFT ID number: _____________________
25. Are you able to wait outside without assistance or support for up to 10 (ten) minutes?
☐
Yes
☐
No
☐
Sometimes
If you indicated ‘no’ or ‘sometimes’, please explain:
26. Do you have the ability to recognize landmarks of your destination without assistance?
☐
Yes
☐
No
☐
With assistance from _______________________
27. Do you have the ability to deal with unexpected changes in your route?
☐
Yes
☐
No
☐
Sometimes
If you indicated ‘no’ or ‘sometimes’, please explain:
28. Have you ever gotten lost while traveling alone?
☐
No, I’ve never been lost while traveling alone.
☐
No, I’ve never been alone.
☐
Yes, I’ve been lost.
29. If you answered yes, were you able to find your way back?
☐
Yes, I was able to find my way back, alone.
☐
Yes, with help.
☐
No.
30. If you couldn’t find your way back, what did you do? Please explain what happened:
Page 7 of 10
Living Independently Facilitated by Transportation
5081 Fred Wilson
El Paso, TX 79906
915.212.LIFT (5438)
Are you currently a LIFT Passenger?
☐ Yes ☐ No
LIFT ID number: _____________________
31. Do you utilize a smart phone, if so are you able to contact Sun Metro for assistance with
route information?
☐
Yes
☐
No
☐
Sometimes
If you answered ‘no’ or ‘sometimes’, please explain:
32. Would you be interested in learning how to utilize the fixed route through Travel Training
with a certified trainer? This program is free of charge.
☐
Yes
☐
No
33. Should we have further questions regarding your application, do you authorize Sun
Metro LIFT to contact your Doctor and/or Certified Agency for further questions?
☐
Yes
☐
No
34. List the top (3) three locations that you often travel with your current mode(s) of
transportation.
A. Where do you go? _____________________________________________________________
Address? ______________________________________________________________________
How often do you go there? ___________________________________________________
How do you get there now? ____________________________________________________
B. Where do you go? _____________________________________________________________
Address? ______________________________________________________________________
How often do you go there? ___________________________________________________
How do you get there now? ____________________________________________________
C. Where do you go? _____________________________________________________________
Address? ______________________________________________________________________
How often do you go there? ___________________________________________________
How do you get there now? ____________________________________________________
Page 8 of 10
Living Independently Facilitated by Transportation
5081 Fred Wilson
El Paso, TX 79906
915.212.LIFT (5438)
Are you currently a LIFT Passenger?
☐ Yes ☐ No
LIFT ID number: _____________________
Functional Ability Questionnaire
Your answers to the following questions will help Sun Metro LIFT better understand your
functional ability in specific areas. For each question, please check one answer. Your answer
should be based on whether you can perform this activity independently without assistance.
Can you…
1. Use the telephone to call Sun Metro for route information and schedules?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
2. Walk up and down (3) three steps if there are handrails?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
3. Walk up or down a gradual hill on the sidewalk, if the weather is good?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
4. Find your own way to the bus stop if someone shows you the way once?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
5. Are you able to walk up to (1) one city block without taking a rest break?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
Page 9 of 10
Living Independently Facilitated by Transportation
5081 Fred Wilson
El Paso, TX 79906
915.212.LIFT (5438)
Are you currently a LIFT Passenger?
☐ Yes ☐ No
LIFT ID number: _____________________
6. Are you able to wait (10) ten minutes at a bus stop that has no shelter or bench?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
7. Are you able to cross a controlled intersection within the allotted time provided?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
8. Are you able to travel alone?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
9. Are you able to transfer from one fixed route bus to another fixed route bus?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
10. Are you able to navigate through a fixed route terminal independently?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
11. Are you able to verify, and pay the correct fare?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
Page 10 of 10
Living Independently Facilitated by Transportation
5081 Fred Wilson
El Paso, TX 79906
915.212.LIFT (5438)
Are you currently a LIFT Passenger?
☐ Yes ☐ No
LIFT ID number: _____________________
12. Are you able to keep track of time?
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
13. Are you able to provide personal information? (i.e., phone number, name, address)
☐
Always
☐
Sometimes
☐
Never
☐
Not Sure
If you answered ‘never’ or ‘Not Sure’, please explain:
14. Did you require assistance in completing this application?
☐
Yes
☐
No
If yes, how did that person assist you?
Important: Sun Metro LIFT will only use this information to determine your eligibility to use Sun
Metro LIFT. Sun Metro LIFT will keep this information confidential and secure and will only use it
for transportation-related purposes. Sun Metro LIFT may also use the contact information
provided to solicit feedback about the LIFT, including providing the telephone and name to a
third-party to carry-out periodic surveys. If you do not wish to participate in surveys or receive
calls regarding the LIFT’s service, check here: ☐
I certify that all information is true and correct. I agree that if any information given to Sun
Metro LIFT is false or misleading, Sun Metro LIFT may reconsider my right to participate in the
Sun Metro LIFT program. I understand, I may be asked to an in-person interview to verify the
information provided is correct. If asked to come in, Sun Metro LIFT will provide transportation.
Signature: ______________________________ Date: ______________________________
