Paratransit Access Line

Part 1

 

Schedules Effective
June 22, 2008
Through Augsut 30, 2008

 

APPLICATION FOR PARATRANSIT SERVICE
TO BE COMPLETED BY THE APPLICANT

Part I can be completed by you alone or with the assistance of another person.

Please answer all questions contained in Part I of the Application.  Failure to answer any question or to provide a recent photograph will delay processing your application. 

Those questions, which require explanations, should be brief, but accurate.

When you have completed Part I, please forward it, along with Part II, to a licensed or certified health care professional (refer to the list in Part II) who is currently treating you for your disability. 

The information on this form will be used solely for the purpose of determining eligibility for the Paratransit Access Line.  The information that you furnish will be kept strictly confidential.

Name:
Address:
City: _________________State: __________Zip Code:__________

Home Phone: _______________      Work Phone:_______________

Date of Birth (Month/Day/Year):____________        Social Security:_______________

1. Do you have a disability?  Yes or No.   If yes, please describe any physical, mental, visual or cognitive disabilities, which prevent you from using the fixed route bus system.

How does this disability prevent you from boarding, riding, exiting or navigating the fixed route system?

(Please attach any additional documentation which you feel will support your inability to travel to and from a boarding or disembarking location, or to board, ride or exit a fixed route bus.)

If no, please explain why you think you are eligible for Paratransit.

 

2. Is your disability a permanent condition?  Yes or No

If no, how long do you expect to have this disability?

3. Do you use any of the following mobility aids?  (Please check all that apply) Motorized Wheelchair, Manual Wheelchair, Powered Scooter, Personal Care Attendant, Sighted Guild or Escort,
Walker, Cane, Crutches, Service Animal, Prosthesis

4. Can you walk/travel 200 feet without the assistance of another person?
Yes, no or sometimes.

Can you walk/travel ¼ mile without the assistance of another person?

Yes, no or sometimes.

Can you walk/travel ¾ mile without the assistance of another person?

Yes, no or sometimes.

Can you climb three 12-inch steps without assistance?

Yes, no or sometimes.

Can you wait outside without support for ten minutes without assistance?

Yes, no or sometimes.

Can you deposit your bus fare independently?

Yes, no or sometimes.

5. Where is the closest bus stop to where you live?

6. How far is this stop from where you live?  Within a city block, ¼ mile, ½, ¾, unsure

7. Do you currently ride a Metro fixed route bus/rail independently? Yes, no or sometimes.

8. Have you ever received mobility training to use the Metro bus system? Yes or No

If yes, what was the year you received that training?

Name of Training Person/Agency:__________________________________________________________________

Address:________________________________________________________________

City:____________________________State:___________Zip Code:________________

Was the training complete?  Yes or No  

9. Does weather impact your ability to travel?  Yes or No 

10. How do you currently travel? Van Service(s), Agency Transportation, NFTA Metro Bus/Rail, Taxi, Other___________

11. Does Medicaid, Social Services, or your school system provide you with transportation to any of the following programs or activities (check all that apply): Nutrition, Community Action Programs, Senior Centers, Workshop, Day Treatment, Retire Senior Volunteer Program, Medical Appointments, Community Residence, School/Day Care, Other___________

If yes, please explain how weather condition(s) impact your ability to ride the fixed route bus/rail system.

I hereby affirm that the statements made herein are true and correct and I authorize the completion of this form and/or the release of related information to NFTA, Special Services Department.

Signature of Applicant 

Date

If someone other than the applicant completed this form on behalf of the applicant, that person must complete the following:

Name:__________________________________________________________________

Address:________________________________________________________________

City:____________________________State:___________Zip Code:________________

Signature_________________________________________Date:___________________

Please enclose a recent photograph of yourself to be used on your Paratransit identification card.  The photo can be any size, however, the picture of your face must fit into the box below.  The photo will be returned if Paratransit service is denied.

 

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