Application for Specialized Services

Application for ADA Paratransit & Specialized Transit Services

Thank you for choosing Metro Connection for your transportation needs. Metro Connection, a division of Shoreline Metro, provides ADA Paratransit and Elderly and Disabled Transportation for eligible and certified customers! The application below if the first step to ensuring your independence!

Applications will be reviewed in a timely manner. A letter of determination will be sent to the applicant within 21-days of receipt of the completed application. Any incomplete or inaccurate applications may delay the certification process. Submission of this application does not guarantee eligibility.

Questions or comments regarding the application or to request the application in an alternative format, please contact Metro Connection at (920) 459-3281, Option 2. To translate this application, please click the “Translate” button in the lower right of this page.

DIRECTIONS: Application is a fillable form. Please fill out the application completely and accurately. Fields marked with an * are required. Press the “Submit” button once application is complete. The application submits electronically to Shoreline Metro for review and consideration. You will receive a confirmation response if the application was submitted successfully.

Application Date *

This is the date the application was submitted.

Applicant Name *

First

Last

Applicant Address *

Address Line 1

Address Line 2

City

State

Zip Code

Facility Name (if living in a facility)

Applicant Gender *

Applicant Date of Birth *

Age of Applicant *

Applicant Primary Phone Number *

Applicant Secondary Phone Number

Would you (the applicant) like a Self-Service account setup so you can schedule trips using the Metro Connection On-Demand app on your smartphone, tablet or Personal Computer? *

Customers are able to schedule trips, receive trip alerts, view their bus, make payments and cancel trips using the Metro Connection On-Demand app. Customers must have a smartphone, tablet or personal computer in order to access these features. For more information, visit the Schedule a Trip page under the Metro Connection menu at www.shorelinemetro.com.

Applicant Email

REQUIRED if you answered YES to the previous question.

Do you (the applicant) receive Medical Assistance (Medicaid)? *

Otherwise known as Title XIX or MA (not to be confused with Medicare) – Customers are encouraged to contact Veyo, the Non-Emergency Medical Transportation provider in accordance with benefits.

Which best describes your (the applicant) current living situation? *

I live independently (without the assistance of another person)
I live with family members who assist me
I receive in-home assistance
Assisted-Living Facility
24-Hour Care or Skilled Nursing Facility

Please check all that apply.

Do you (the applicant) require the use of a mobility aid? (copy) *

If yes, what type(s) of device(s)?

Manual Mobility Device (wheelchair)
Powered Mobility Device (scooter, chair)
Walker (non-powered)
Cane/Crutches
Transport Chair (requires customer to transfer to seat)

Please check all that apply. The Americans with Disabilities Act (ADA) requires public transportation programs to service those individuals in a mobility device if the lift and vehicle can physically accommodate the passenger. If accommodations become inconsistent with legitimate safety requirements, the ADA does not guarantee your trip. This clause is observed by all specialized and non-specialized transportation services provided by Shoreline Metro.

If you (the applicant) use a Mobility Device, what is the estimated combined weight of you and the device?

Mobility Device Picture

Click or drag files to this area to upload. You can upload up to 3 files.

Metro Connection performs assessments on mobility devices to ensure they’re safe and appropriate to ride in on our vehicles. Assessments can be made through photographs of the device. In some cases, an in-person assessment may be required.

Can you (the applicant) travel from your residence to the curb or sidewalk without assistance? *

How many city blocks can you (the applicant) travel without the assistance of another person? *

2-3 city blocks equals 1/4 mile.

Can you (the applicant) wait outside without support for 10-minutes? *

This means without the need or requirement to sit.

Is your (the applicant) ability to travel affected by any physical, architectural or natural barriers? (This may include weather, terrain, bridges, busy intersections, etc.) *

If you answered yes, please explain these barriers.

Do you (the applicant) have a disability? *

Please select your disability type (select all that apply). *

Physical
Mental
Cognitive
No Disability

Cognitive is defined as ability to perceive and react, process and understand and make decisions and produce responses.

What is the duration of your disability? *

Temporary (0-6 months)
Short-Term (6-12 months)
Permanent
No Disability

Duration is how long the disability is expected to impact the applicant. Please select “Permanent” if the disability will impact you permanently and will never improve over time.

If you have a disability, please describe your (the applicant) disability in detail.

Describe how your disability impacts your ability to travel and use public transportation. Please include specific terms and medical conditions.

When did you first experience the condition(s)?

What level of assistance is required with this disability?

Please indicate the level of assistance that is required in order for you do daily activities.

Does this condition(s) change from day-to-day?

Have you (the applicant) ever used Shoreline Metro (city bus)? *

Shoreline Metro is the fixed route, public transit service with bus stops available on all corners along each route.

If travel training was provided to assist with using Shoreline Metro (city bus), would you be able to use it with or without accommodations? *

Shoreline Metro is the fixed route, public transit service with bus stops available on all corners along each route.

If you (the applicant) live in Sheboygan, Sheboygan Falls or Kohler, how does your disability prevent you from using Shoreline Metro (city bus)?

Please do not use abbreviations or acronyms. Be specific.

Do you (the applicant) require the use of any additional aides? *

Personal care attendants may ride at no additional charge. Customer must provide the personal care attendant.

If Yes, please select all required aides.

Oxygen Tank
Translator
Personal Care Attendant (PCA)
Service Animal(s)

Please check all that apply.

If you require a Personal Care Attendant (PCA) to travel with you, please list name and relationship.

Personal Care Attendant #1

If you require a Personal Care Attendant (PCA) to travel with you, please list name and relationship.

Personal Care Attendant #2

My transportation needs are: *

Weekdays 7:30 a.m. to 3:30 p.m. (Sheboygan County’s Elderly & Disabled Program)
Weekdays 5:15 a.m. to 8:15 p.m. (Shoreline Metro’s Paratransit Program)
Saturdays 8:45 a.m. to 3:45 p.m. (Shoreline Metro’s Paratransit Program)

This will help us determine the appropriate program especially if the applicant is over the age of 60. Paratransit service will require an additional In-Person Assessment and/or Doctor’s Verification.

Will you have someone else schedule, cancel or change trips on your behalf? *

By clicking “Yes”, you are authorizing Metro Connection to input trips, cancel trips and make changes to trips as requested by someone other than yourself.

Please provide any additional information on trip scheduling.

This information may include names of authorized individuals, organizations, etc.

Applicant's Emergency Contact Person *

First

Last

Relationship to Applicant *

Phone *

Applicant's Medical Professional/Treating Physician Name *

First

Last

In order for your application to be evaluated, it may be necessary to contact a physician or other professional to confirm the information you have provided. The following professional(s) is most familiar with my disability/health condition and is/are authorized to provide Metro Connection with the information required to complete this certification.

Medical Professional/Treating Physician Type

Medical Professional/Treating Physician Address *

Address Line 1

Address Line 2

City

State

Zip Code

Medical Professional/Treating Physician Phone *

I (the applicant) hereby authorize the above professional to provide the required information to Metro Connection. Furthermore, I understand that it may be necessary for me to participate in an in-person evaluation to determine my eligibility for specialized transportation services. I certify that the information here and on the preceding pages is correct. I understand that falsification of information may result in denial of service. *

I agree
I disagree

If this application has been filled out by someone other than the applicant, please list name.

First

Last

Phone

To the best of my (the applicant) knowledge the above information is true and factual. I understand that falsification, distortion, or misrepresentation of information may result in denial of service. Further, an incomplete application may delay in the certification process and may result in the process taking longer than 21-days in accordance with ADA law *

I agree
I disagree

Additional Comments

Once complete, scroll down and press the SUBMIT button.

Upload Documents

Click or drag files to this area to upload. You can upload up to 5 files.

Please upload any additional documents for consideration including physician documentation, letters, and photos of mobility device. Additional documentation can help us in the application process, but is not required.

APPLICATION IS COMPLETE – CLICK "SUBMIT".

The Shoreline Metro ADA Coordinator will be in contact shortly regarding your application. Upon completion of this application, Shoreline Metro may 1) request additional information from a medical profession, 2) schedule an in-person home assessment, or 3) schedule an evaluation using Shoreline Metro (city bus).