Disabled Adults Transportation Services Registration

This form is for Disabled Adults, over the age of 18, wishing to request transportation by Schaumburg Township.

If you are a Senior, aged 55 and older, wising to request transportation by Schaumburg Township, please visit our Transportation page and fill out the Senior Transportation Services Registration Form.

Your Name(Required)

Your Name

First Last

Birth Date(Required)

Home Address(Required)

Home Address

Street Address Address Line 2 City ZIP / Postal Code

Email(Required)

Enter Email Confirm Email

Nearest Major Cross Streets(Required)

Phone(Required)

Alternate Phone(Required)

Gender(Required)

Gender

Male

Female

Prefer not to answer

Ethnicity(Required)

Ethnicity

Number of individuals in the home(Required)

If you live alone, please enter 1.

Emergency Contact Name(Required)

Emergency Contact Name

First Last

Emergency Contact Relationship(Required)

Emergency Contact Phone(Required)

Emergency Contact Alternate Phone

Please describe your disability(Required)

Please check all that apply:(Required)

Please check all that apply:

Mobility Limited

Hearing Impaired

Respiratory Disability

Visually Impaired

Speech Impaired

Neurological Disability

Aids Used (if any)

Wheelchair

Walker

Braces

Prosthetic Device

Attendant

Crutches or Cane

Service Animal

Any other aids used

Do you own a TTY (Telecommunications for the Deaf)?(Required)

Do you own a TTY (Telecommunications for the Deaf)?

Yes

If yes, what is the TTY number?

Do you need the Lift-Equipped Bus?(Required)

Do you need the Lift-Equipped Bus?

Yes

Below Poverty(Required)

Below Poverty

Yes

What is your primary language spoken?(Required)

Electronic Signature(Required)

Please enter your full name to serve as your electronic signature for this form.

Today's Date(Required)

Physician's Letter Requirement

In order for this form to be considered completed and thus processed for acceptance, the Transportation Department must receive a Physician's Letter stating that the applicant on this form is disabled. The letter must include the Physician's Name, Address and Phone, as well as the current date, the Physician's signature and the Physician's License Number. This letter may be mailed to the Schaumburg Township Transportation Department at 1 Illinois Blvd., Hoffman Estates, IL 60169; may be faxed to 847-884-0039; or may be emailed to jmalave@schaumburgtownship.org.

Disabled Adults (18+) Transportation Services Registration

This form is for Disabled Adults, over the age of 18, wishing to request transportation by Schaumburg Township.

Physician's Letter Requirement

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