Paratransit Mobility Device Information Sheet
Rider Information
Name
Phone Number
Email
Address
Mobility Device Details
Type of Device
Manual Wheelchair
Power Wheelchair
Scooter
Other
Brand/Model
Length (inches)
Width (inches)
Height (inches)
Weight (lbs)
Is device foldable?
Yes
No
Does the device have removable parts?
Yes
No
Batteries (If Applicable)
Type of Battery
Sealed Lead Acid
Gel
AGM
Lithium-Ion
Other
Battery Quantity
Additional Information
Notes or Special Instructions