Office for Disabled Travel Training Referral Form

If you would like make a referral to the Travel Training Program, please complete the following form and mail it to the address below. (* indicates required field)
*Name of Consumer:
*Address:
*City:
*Zip:
*Phone Number
*Date of Birth:	mm/dd/yy
*Contact Person:
*Contact Daytime Phone:
Email:
*Date of Referral:	mm/dd/yy
*Referred by:
Agency/School if applicable:
*Destination Site:
*Desired Date to Begin:	mm/dd/yy
Is consumer currently a ParaTransit user?: yes No
Additional Information or Comments

           Anna M. Masopust
          Westchester County
          Office for the Disabled
         148 Martine Ave. Rm. 102
         White Plains, NY 10601
         Tel.# (914) 995-2959
         Fax # (914) 995-2799