Dial-A-Ride
And
Application Form
LRTA Office for Transportation Access
(978) 459-0152
PART A
(This part
must be completed by all applicants)
1. NAME ________________ ______
______________________ SEX
(M/F)___
First M.I. Last
Social Security
Number __________________________
ADDRESS_______________________________________
APT. #_____________
CITY
___________________ STATE___________ ZIP CODE________________
EMAIL:
_______________________
DATE OF BIRTH
______________________
PHONE ( )__________________ (
)________________________
Home Work
2. EMERGENCY CONTACT (if applicable)
NAME ________________ ______________________
PHONE ( )
___________________ ( )_______________________
Home Work
RELATIONSHIP TO YOU
__________________________
Do you have a disability or health condition that prevents you from
sometimes using LRTA fixed route buses?
0 No, I am
applying based only on my age (60 or older). ATTACH A COPY
OF DOCUMENTATION OF YOUR AGE (government ID).
STOP HERE. You do not need to
complete PARTS B and C below. Return
this form to LRTA at the address shown above to become eligible for Dial-A-Ride
service.
0
Yes, I am applying for “
PART B
This part only needs
to be completed if you have a disability or health condition that prevents you
from sometimes or always using LRTA’s fixed route bus
service. Persons completing this section
will be considered for “ADA Paratransit
Eligibility.” Information about
disability or health condition will be kept strictly confidential.
1. What is your disability or health condition and how does it prevent you from using LRTA buses some or all of the time?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
2. Is
your disability temporary? ______
If YES, how long is it expected to last? ____ Months ____ Years
3.
Do you ever need to bring someone else with you
to help you when you travel (a Personal Care Assistant PCA)?
Yes____
No____ Occasionally ____
4. Legal Blindness
(total) _____ (low
vision) _____ (visually impaired but
not legally blind)
____
Dialysis patient ______ Hearing impaired ______ Deaf ______
5.
Do you use a mobility aid or equipment to
travel? _______
PAGE 2 of 5
6. WHICH OF THE FOLLOWING MOBILITY AIDS OR EQUIPMENT DO YOU USE TO HELP YOU GET WHERE YOU NEED TO GO?
(Please check all that apply)
7. Can
you, using the mobility devices you identified above:
ENTER A VEHICLE WITHOUT A RAMP OR A LIFT? Yes____ No____
If sometimes, explain which conditions would prevent
you__________________________
WALK SAFELY 200 FEET WITHOUT THE ASSISTANCE OF ANOTHER PERSON?
Yes____
No____ Sometimes____ If sometimes, explain which conditions would
prevent you________________________________________________
WALK SAFELY 1/4 MILE WITHOUT THE ASSISTANCE OF ANOTHER
PERSON?
Yes____
No____ Sometimes____ If sometimes, explain which conditions would
prevent you________________________________________________
WALK SAFELY 1/2 MILE WITHOUT THE ASSISTANCE OF ANOTHER
PERSON?
Yes____
No____ Sometimes____ If sometimes, explain which conditions would
prevent you________________________________________________
WALK SAFELY 3/4 MILE WITHOUT THE ASSISTANCE OF ANOTHER
PERSON?
Yes____
No____ Sometimes____ If sometimes, explain which conditions would
prevent you________________________________________________
CLIMB SAFELY THREE 12-INCH STEPS WITHOUT ASSISTANCE?
Yes____ No____ Sometimes____ If sometimes, explain which
conditions would prevent you________________________________________________
WAIT OUTSIDE WITHOUT FOR TEN MINUTES WITHOUT SITTING ON A
BENCH?
Yes____ No____ Sometimes____ If sometimes, explain which
conditions would prevent you________________________________________________
PAGE 3 of 5
8. I CERTIFY THAT THE
INFORMATION GIVEN ABOVE IS CORRECT TO THE BEST OF MY KNOWLEDGE.
__________________________________
Applicant's
Signature
In our correspondence to you, which format would you prefer:
Large Print_____ Audio Tape_____
**IMPORTANT**
The information provided by your human service or health care professional
on page # 5 will only be used to help the
LRTA decide if you are eligible for the ADA RoadRunner
and to make sure that we understand your travel needs. If
page # 5 is incomplete we cannot determine your eligibility. This
personal information will only be shared with people who will be providing you
with your transportation.
HUMAN SERVICE OR HEALTH CARE PROFESSIONAL ASSESSMENT
9. I hereby authorize my human service or health care professional to release any information necessary to determine RoadRunner eligibility to the LRTA.
Applicant's Signature:_____________________________
Date:____________
faxed
applications are not accepted.
PAGE 4 of 5
PART C
***TO BE COMPLETED
BY HUMAN SERVICE OR HEALTH CARE PROFESSIONAL***
IMPORTANT
NOTICE TO HUMAN SERVICE OR HEALTH CARE PROFESSIONAL: The information which you provide will assist
us in determining the applicant's functional
ability to use public transportation.
It is essential that you be as precise and comprehensive as possible in
your evaluation. Thank you for your cooperation.
PLEASE TYPE OR
PRINT
Applicant's Name_________________________________________________________________
Address_________________________________________________________________________
Professional relation to the
applicant_________________________________________________
Please provide (type or print) a
narrative assessment of the applicant's functional level of mobility,
describing any other effects of the disability, and noting whether you agree
with the applicant's assessment of his/her functional ability to use LRTA
buses:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Is the applicant able to:
Give
information such as address and telephone number upon request? Yes____ No____
Recognize a destination or landmark? Yes____ No____
Deal with unexpected situations or unexpected change in
routine? Yes____ No____
Ask for, understand and follow directions? Yes____ No____
Safely
travel through crowded and/or complex LRTA facilities? Yes____ No____
Safely walk ¼
mile without assistance? Yes____ No____
I CERTIFY THAT THE INFORMATION GIVEN ABOVE IS CORRECT TO THE BEST OF MY
KNOWLEDGE.
__________________________________________
LICENSED/CERTIFIED
HUMAN SERVICE OR
(Please type
or print the following) HEALTH
CARE PROFESSIONAL
NAME_____________________________ TITLE/LICENSE
#_________________ DATE__________
BUSINESS BUSINESS
PHONE _________________________ ADDRESS ____________________________________
Completed
form must be returned to: LRTA Office for Transportation Access