Access Maryland Pass Application

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Application for Access Maryland: State Park Pass
For Persons with Disabilities
(Non-transferable)
Maryland Park Service
Please Type or Print Clearly

Name: _________________________________________________________________________
(first) (middle initial) (last)

Address: ______________________________________________________________________
(street) (city) (state) (zip code)

Date of birth: _____________ Telephone Number: _____________________

Height: __________ Weight: ______ Hair color: _______ Eye color: ________

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Nature of Disability (TO BE COMPLETED BY PHYSICIAN OR APPROPRIATE HEALTH CARE PROVIDER)

Description and location of disability:

_________________________________________________________________________________

_________________________________________________________________________________

I hereby certify that the above diagnosis is correct, and that the disability is PERMANENT AND SUBSTANTIALLY LIMITS ONE OR MORE MAJOR LIFE ACTIVITIES of the above-named applicant.

Signature of Physician or Appropriate Health Care Provider: ___________________________________

Print Clearly or type Physician's or Health Care Provider's Information: ____________________________________

Name:_____________________________________________________________

Address of Physician: _____________________________________________

____________________________________________________________

Date: __________
Telephone Number: __________________

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The Access Maryland State Park Pass is a free lifetime entrance pass to those State operated parks with entrance service charges. It is issued to persons who have a permanent physical or mental impairment that substantially limits one or more major life activities. Having reserved parking tags or a "handicapped" placard from the Motor Vehicle Administration does not constitute disability status for the purpose of this pass. Confirmation from a physician or appropriate health care provider is still required. The Access Maryland State Park Pass admits the card holder and one other person only.

Complete application and return to:

Maryland Department of Natural Resources
Maryland Park Service
Tawes State Office Building
580 Taylor Avenue, E-3
Annapolis MD 21401
Attention: Access Maryland Pass Application
Telephone Number: 410-260-8186 (Voice)
Telephone Number: 410-260-8835 (TTY)

Upon review and approval of application your Access Maryland State Park Pass will be mailed to you.

Signature of Applicant: ________________________________________________

Date: ____________________________

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