Disability Resource Center Verification of Mobility Impairment The DRC Verification of Mobility Impairment form must be completed, signed (a digital signature is acceptable) and returned to DARTCART@asu.edu. Today's Date Due Date ASU ID The Disability Resource Center (DRC) provides on-campus transportation to students, staff and faculty with limited mobility due to a medical condition(s). Any participant with an ambulatory disability is required to have this form completed by their attending medical provider. Please return completed form by fax or email to DRC@asu.edu upon receipt of this verification Services will be suspended if the form is not complete and/or not returned by the deadline indicated above. Name I Acknowledge By checking this, I declare that I give permission for my medical provider to release relevant medical information to Disability Access and Resource Transportation (DART) located at Arizona State University, DRC for the purpose of making the appropriate accommodations. You can reach me at Primary campus - Select -TempePolytechnicWestDowntown Phoenix Other campuses you take classes on - None -TempePolytechnicWestDowntown Phoenix I Acknowledge By checking this box, I acknowledge that I have read and understand the terms and conditions and that all the above information I have provided is correct to my knowledge. Print Name Date TO BE COMPLETED BY MEDICAL PROVIDER Your Patient has requested transportation services on the basis of a medical condition that significantly impacts his/her ability to walk. It is necessary to complete the following information in order that we may provide the accommodation. Information provided will remain confidential and will not be shared with anyone. Please take into account the environmental conditions that may also impact the patient’s condition. ie: intense summer heat, etc A. Describe injury/illness: B. Patient is limited to walking feet C. Patient’s maximum walking distance is feet. D. Patient is expected to begin walking on own in week(s). (weight bearing, rehabilitation, etc.) E. Patient is expected to fully recover in weeks(s). MEDICAL PROVIDER INFORMATION Medical Provider's Name Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Office Phone Fax Comments I Acknowledge By checking this box, I acknowledge that I have read and understand the terms and conditions and that all the above information I have provided is correct to my knowledge. Print Name Date Leave this field blank