SONOMA COUNTY REGIONAL PARKS DEPARTMENT
Access Membership Application Phone (707) 565-2041 Fax (707) 579-8247
website: sonomacountyparks.org
e-mail: parks@sonoma-county.org
Eligibility Requirements
For purposes of this program, a permanently disabled person is defined as anyone who: 1) has a
physical or mental impairment which substantially limits one or more of such person’s major life
activities; and 2) has a current record of such impairment.
To be eligible for an Access Membership, the applicant must possess one of the following
permanent disabilities:
DEVELOPMENTAL Persons who meet the legal definition of, or have been identified as
developmentally disabled. This includes autism, cerebral palsy, intellectual disability, etc.
HEARINGPersons who have total deafness or are unable to hear with the aid of an assistance
device on the level that meets the standards of the American National Standards Institute (ANSI), as
determined by an audiometer.
MENTAL
Persons who have any mental disorder on the level of severity that restrict activities of daily
living, social functioning, or concentration.
PHYSICALPersons who have any of the following physical disabilities:
A. MobilityOrthopedic impairments, amputations, or functional limitations where there is: 1) loss
or significant impairment of one or both upper extremities; or 2) loss or significant impairment of
one or both lower extremities; or 3) impairment of the trunk, back or spine that is a medically
diagnosed disability, which substantially limits
one or more major life activities, impairs or
interferes with mobility, or requires the aid of an assistance device for mobility.
B. CardiovascularSevere cardiac impairment resulting from one of three consequences of
heart disease: 1) congestive heart disorder; or 2) ischemia with or without necrosis of heart
muscle; or 3) conduction disturbances and/or arrhythmias resulting in cardiac syncope; or 4)
chronic venous insufficiency, or peripheral arterial disease with intermittent claudication.
C. RespiratoryLung disease to such an extent that force expiration volume at one second,
when measured by spirometry, is less than one liter, or arterial oxygen tension (PO
2
) is less
than 60 mm/HG on room air at rest. Also, persons with episodic asthma, chronic bronchitis,
etc.
D. NeurologicalMultiple sclerosis and other neurological disorders such as epilepsy and
Parkinsonian syndrome.
SPEECHPersons who have a loss of speech from glossectomy or laryngectomy, or from cicatricial
laryngeal stenosis due to injury or infection that resulted in the loss of voice production by normal
means.
VISUALPersons whose remaining vision in their better eye, after best correction, is 20/200 or less as
measured by the Snellen test. Also, persons with a substantial limited visual field, visual efficiency and
homonymous hemianopsia, etc.
Est. 8/97 Rev 07/15
Business Phone No.
City / State / Zip
Business Address
Doctor’s Name Professional License No.
SONOMA COUNTY REGIONAL PARKS DEPARTMENT
Access Membership Application Phone (707) 565-2041 Fax (707) 579-8247
website: sonomacountyparks.org
e-mail: parks@sonoma-county.org
V PermDM anently Disabled Person Vehicle License Plates (attach copy of vehicle registration)
DMV Permanently Disabled Person Parking Placard (attach copy of placard registration)
I. INSTRUCTIONS
The annual Access Membership entitles its bearer to day-use parking and discounts on camping fees. Service and guide dogs are
permitted at no charge. The cost of this membership is $29 (price subject to change). The membership is not transferable and
may be revoked at any time for misuse. To
qualify,
you must have a permanent disability as defined in the Eligibility Requirements.
Applicants must provide Sonoma County Regional Parks a permanent disability certification per Section III or Section IV below.
To apply, complete Sections II, III and V of this application and attach proof of disability as described (a doctor must complete Section
IV only if you are qualifying with a doctor’s certification that you are permanently disabled). Applications and payment may be
presented in person or mailed with check, money order (made payable to County of Sonoma), or credit card information to:
Sonoma County Regional Parks, 2300 County Center Drive, Suite 120A, Santa Rosa, CA 95403
II.
APPLICANT INFORMATION - Applicants are hereby notified that this application is subject to disclosure under the California
Records Act.
Name (Last, First, Middle Initial – please print or type) Daytime Phone No.
Address
City / State / Zip
E-Mail Address:
III.
CERTIFICATION TYPE (check one)
State Regional Center Certification (attach copy)
SSI or SSDI Verification (attach copy of SSI Payment Decision or SSDI Award Certificate)
Doc
Med
tor Certification (Doctor must complete Section IV below)
icare Card - if under the age of 65 (attach copy of card and proof of age)
IV.
DOCTOR CERTIFICATION -
I certify that the applicant has one of the permanent disabilities defined on the reverse of this form.
Doctor’s Signature & Date
Date:
V. APPLICANT CERTIFICATION - I certify under penalty of perjury that I am permanently disabled and that the foregoing is true and correct.
Applicant’s Signature & Date
Date:
For Department Use Only
Issued by:
Remarks:
Date:
Membership No.:
Est. 8/97 Rev 07/15