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Document Signers
    • 1 Applicant

    • 2 Health Care Provider

    • 3 Elroy Golemon, Capital Transit Superintendent

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Welcome to the City of Helena's Application for Paratransit Services

To submit this form online, the applicant must be prepared to include a health care provider's name and email address. There are three parts to this application. You may also print this form and contact your health care provider to complete that section before submitting it to the transit office.

  1. The first section is completed by the applicant to describe the disability that limits the ability to ride the fixed route bus.
  2. The second section is the medical release form to be completed by the applicant to allow a health care provider to complete the authorization form, confirming the disability stated by the applicant. Upon submission of section 1, the applicant will be immediately directed to complete the release form.
  3. Section three is completed by the health care provider, which requires the applicant to enter the health care provider's name and email address when submitting the application.

When all three steps are completed, the application packet will be reviewed by the director of our transit system and approved or denied. The applicant will be notified of the status within 21 business days of submission of the complete packet.

Please check that you agree before continuing.
I acknowledge that I am authorized to complete this form, and understand that to submit it online, I must provide a health care provider's name and email address.
Signature HereClick to Sign
12/09/2018Click to Sign
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Signature HereHealth Care Provider Will Sign Here
12/09/2018
12/09/2018
Signature HereElroy Golemon, Capital Transit Superintendent Will Sign Here

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