City of Colorado Springs / Transit Service / Paratransit / Metro Mobility / ADA Application Request Form

ADA Application Request Form

TRANSIT SERVICES DIVISION OF THE CITY OF COLORADO SPRINGS

To request that ADA barriers, barriers defined as anything in the city right-of-way that blocks or impedes passage of pedestrians or persons with disabilities to the transit system.

APPLICATION FORM – INDIVIDUAL REQUESTS FOR REMOVAL OF PEDESTRIAN BARRIERS

Name:                  __________________________________________________________

Address:              __________________________________________________________

Phone #:              __________________________________________________________

For the purpose of this form, Barriers are defined as anything in the city right-of-way that blocks or impedes passage of pedestrians or persons with disabilities.  Please check the appropriate barrier or describe in Other:

Pedestrian Ramps_____   Overgrown trees or shrubs _____ Missing/Damaged Sidewalk _____

Cross Walk _____ Audio/visual Warning System_____ Other____________________________

Priority will be given to projects/routes that convert transit trips from paratransit service to fixed route service, and projects that involve facilities that have a high usage by the disabled community.  Removal of barriers is dependent on prioritization and the availability of funding and resources. 

Please describe the barrier in detail including location by address: _____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________

If more than one physically disabled person will use the same route, please list the approximate number of times per week the route will be used:  __________________________________________

Please list applicants and any other known person with disabilities who will use this pedestrian route:

 

Name	Address	Phone Number	Signature

 

Location Sketch  - Provide a general sketch with required information listed below on the sketch form on the reverse side of this document; include items 1-5 listed below:

1. Sketch street system and label all streets.
2. Generally locate and label origin (such as address of residence) and destination (such as employment address or bus stop of trip).
3. Mark each requested barrier location with an X
4. Show route travel by use of arrows

Please mail or present your form to:  Mountain Metropolitan Transit

                                                                           1015 Transit Drive

                                                                           Colorado Springs, CO 80903

 

Please Place Sketch Here

Please add any notes or descriptions below: __________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

____________________________________________________