Application for Dial-A-Ride Transportation (DART)

Transcription

1 DART USE ONLY 1A 1B 9A 9B Temp Duration INC / DEN / CERT Date Other Agency Access Date Status Funding Code MV Due By MV1 45 Days NEW RECERT CLIENT # E T Application for Dial-A-Ride Transportation (DART) This application is exclusively for residents of Snohomish County, Washington. LAST NAME FIRST NAME INITIAL APPLICANT INFORMATION (please print clearly) Last Name First Name Middle Initial Residence Address Street Unit/Sp/Apt # City State Zip Name of Complex or Facility: Mailing Information (if different) Name Street or PO Box Unit/Sp/Apt # City State Zip Date of Birth - - Gender (please circle) M F Contact Information Home Phone Cell Phone Emergency Contact Last Name First Name: Relationship to applicant: Home Phone Alternate Phone Cell Home Work Rev. May 13, 2015

2 QUALIFYING DISABILITY (please print clearly) 1. What is the health condition or disability that would prevent your use of the fixed route bus, some or all of the time? Be specific. 2. Please explain how the above: Prevents you from getting to or from a regular, fixed route bus stop? Prevents you from waiting at a regular, fixed route bus stop? Prevents you from getting on or off a regular bus? Prevents you from being able to ride a regular, fixed route bus or to understand and follow transit instructions? 3. Is the medical condition or disability above: Temporary, I expect it to last another months. Permanent Unsure Rev. May 13, 2015

3 CURRENT MOBILITY (please print clearly) 1. How have you most recently been traveling? CHECK ALL THAT APPLY: PUBLIC TRANSPORTATION PARATRANSIT OTHER Community Transit Bus DART Walk Everett Transit Bus Access Paratransit Bicycle Metro Transit Bus Everett ParaTransit Drive Sound Transit Bus Hopelink Taxi Train Ride in a Car If you are able to drive, will you be doing so in the future? Yes No 2. Have you ever used the regular fixed route buses independently? Yes, I typically used regular buses a week. Yes, I used to but stopped because (please be specific) No 3. What accommodations would assist you in using the fixed route bus system? Route & schedule information Bus stops closer to home/destination Accessible bus stop and pathway Bench/shelter at bus stop No transfers Training to use the fixed route bus Other 4. Because of your disability, do weather conditions (such as heat, cold, rain, snow, or ice) prevent you from using a regular bus independently? No Yes - which ones How? 5. Because of your disability, do terrain conditions (such as hills, uneven surfaces, or curbs) prevent you from using a regular bus independently? No Yes - which ones How? 6. Because of your disability, do environmental conditions (such as darkness, bright lighting, or air quality) prevent you from using a regular bus independently? No Yes - which ones How? 7. How many blocks can you walk on your own or using a mobility aid? Rev. May 13, 2015

4 MOBILITY AIDS AND ASSISTANCE (please print clearly) 1. Which of the following mobility aids or equipment do you use when you travel outside of your home? Check all that apply. None Walker (non-folding) White Cane Leg Brace Manual Wheelchair Service Animal Cane/Crutches Power Wheelchair Portable Oxygen Walker (folding) Power Scooter Bus lift Which mobility aid would you primarily use on the DART bus? 2. If you use a wheelchair or scooter: Specifications: Make Model Total length Total width Chair weight Applicant s weight If you use a manual wheelchair: how far are you able to self-propel? What would limit your abilities? If you use a power wheelchair/scooter: How far are you able to travel outside on your own? What would limit your abilities? 3. Do you need to travel with a Personal Care Attendant (PCA)? A PCA is someone who travels with someone who cannot travel alone. No - you may still have a companion travel with you whenever you wish. Sometimes - at your discretion. You must arrange for your own PCA. Yes - if you check this box you are saying that you cannot ever travel alone. There may be times you will be left alone on the DART bus while drivers are assisting other customers. You understand that you must provide your own PCA as DART drivers may not serve as one. 4. If traveling without a PCA, do you require assistance from your door to the bus? No Yes. What type of assistance? Rev. May 13, 2015

5 APPLICANT S CERTIFICATION (please write clearly) DART follows federal and state regulations regarding the confidentiality, storage, and disposal of all information related to your application and provision of service. This information will be kept confidential and shared only with those individuals directly involved with providing the transportation services that you request. Note: For the safety of everyone all of our buses are equipped with audio and video recording devices. I certify under penalty of perjury (RCW 9A ) that the information provided in this application is true and correct to the best of my knowledge. I understand that falsification of information may result in denial of service and criminal penalty. I understand that information provided on this application will be disclosed to others as necessary to provide the services I have requested and as otherwise may be required by law. Applicant s signature Date If someone other than the applicant completed this application, with either the legal authority to do so, or the applicant s permission, please read the above and complete the following. Signature Date Print name Relationship to applicant Phone number Rev. May 13, 2015

6 RELEASE OF INFORMATION (please write clearly) Print Applicant Name Date of Birth The following information is required in order for your current provider to share information with DART, and is needed to evaluate your eligibility for paratransit service. They must be a licensed: health care provider (MD, DO, PA-C, or ARNP), mental health professional (PhD, Clinician III or IV), Audiologist (certified by ASHA), or Orientation & Mobility Specialist. You are applying for ADA paratransit eligibility and the person(s) you list may be asked to describe how your disability prevents you from independently using a regular, fixed-route bus. Information regarding a provider not on the above list is unacceptable. Provider s full name and title Clinic/Agency Phone ( ) Fax ( ) Address City State Zip Code Provider s full name and title Clinic/Agency Phone ( ) Fax ( ) Address City State Zip Code I give permission to the above provider(s) to release information about my disability or health condition. I understand the information will be confidential and used only to determine eligibility for ADA paratransit service. Signature of Applicant Date If applicant is under age 18, has a legal guardian, or cannot complete the Release of Information, this page must be signed by parent/legal representative. I certify under penalty of perjury that I have the legal authority to complete this Release of information on behalf of the applicant. A copy of the medical power of attorney or other authorizing document is attached (required). Signature Date Print Name Relationship to Applicant Rev. May 13, 2015