INSTRUCTIONS TO APPLY FOR e-tran / e-van SENIOR TRANSPORTATION SERVICE

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Maximilian Lyons
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INSTRUCTIONS TO APPLY FOR e-tran / e-van SENIOR TRANSPORTATION SERVICE Thank you for your interest in applying for Senior Transportation Service.

1 INSTRUCTIONS TO APPLY FOR e-tran / e-van SENIOR TRANSPORTATION SERVICE Thank you for your interest in applying for Senior Transportation Service. As a senior citizen, age 75 or older, you are eligible for the Senior Transportation Service in Elk Grove. This transportation service allows you to make a reservation for a door-to-door trip, for any purpose, and will be arranged through e-van services. To apply for Senior Transportation Service, please complete and return the attached information form, together with verification of your age, to the City of Elk Grove Transit Service, Attn: Senior Transportation Services. A copy of one of the following forms of identification that shows your birthdate will serve as proof of age: Driver's license (copy) State of California ID card (copy) Birth Certificate (copy) A valid passport showing date of birth (copy) If you need help filling out the application form, or if you have any questions about Senior Transportation Service, please call for assistance. Please be aware that Senior Transportation Service is a non-ada program, which is funded locally and separate from the e-van/paratransit service that is sponsored by e-tran Service in accordance with the Americans with Disabilities Act (ADA). Federal regulations require that ADA paratransit trips must take priority over any other non-ada programs, and therefore, it is possible that e-tran Senior Transportation Service Applications Rev

2 limitations may be placed on the Senior Transportation Service in the future. If you are concerned about limited service under the Senior Transportation Service, and you have a disabling condition, you may want to consider applying for ADA service. If you are disabled and will need to use paratransit service outside of the City of Elk Grove, we recommend you apply for ADA service. Note: ADA service eligibility requires a more detailed screening process. The evaluation for ADA paratransit eligibility is based solely upon your physical or mental ability to independently use fixed-route (bus and light rail) public transportation. Considerations based on your age and/or economic status will not be used as qualifications for ADA service. If your disabling condition only keeps you from using fixed-route transit under certain circumstances, ADA eligibility for e-van usage may be granted on a restricted or "conditional" basis. A photo identification card is also required for ADA service. It is possible to be eligible for both Senior Transportation Service and ADA e-van service. You may register for senior service now and apply for ADA service at a later date. To apply for ADA service, please call the City of Elk Grove at and request an ADA application. Continued on Next Page e-tran Senior Transportation Service Applications Rev

3 INFORMATION FORM FOR SENIOR TRANSPORTATION SERVICES Once the City of Elk Grove Transit Services receives this completed information form and your proof of age, it should take approximately 2 to 3 weeks to process. When you receive the approved certification letter, please call e-tran/e-van s office to schedule an appointment to have your picture taken for your photo ID at If you do not receive your confirmation letter within 21 days, please call FIRST LAST NAME MI NAME GATE CROSS ADDRESS APT CODE STREET CITY ZIP NAME OF APARTMENT COMPLEX OR CARE FACILITY, if applicable BIRTHDATE / / SSN (last four digits) PHONE DAY ( ) - EVENING ( ) - CELLULAR ( FIRST NAME ) - Please provide the name of a LOCAL friend or relative to contact in an emergency: LAST NAME GATE CROSS RELATIONSHIP ADDRESS CITY ZIP PHONE DAY ( ) - EVENING ( ) - CELLULAR ( ) - e-tran Senior Transportation Service Applications Rev

4 1. Do you have a visual impairment? Yes No If yes, please describe 2. Do you need the assistance of another person to travel? Sometimes 3. Are you able to independently get into and out of a taxicab? 4. Do you need future information given to you in a different format? (If yes, please check ( ) all that apply). If yes, please check your preference: Large print Braille Disk Audiotape Continued on Next Page e-tran Senior Transportation Service Applications Rev

5 MOBILITY AID AND/OR EQUIPMENT INFORMATION Which of these mobility aids do you use? Please check all that apply to you. white cane powered wheelchair* walker support cane 3-wheel scooter/cart* walker with seat crutches manual wheelchair * portable oxygen leg brace power assist wheelchair* prosthesis service animal communication board no mobility aid other (please specify) * Wheelchair means a three or more wheeled mobility device. Is your mobility device oversized? If yes, please explain Does your mobility device weigh less than 600 pounds when occupied? Do you know how much you and your wheelchair weigh together? If yes, please provide the total weight: lbs. Can you transfer from your mobility device into a passenger seat? PRINT NAME SIGNATURE DATE Mail completed form to: City of Elk Grove Transit Services Attn: Senior Transportation Services 8401 Laguna Palms Way Elk Grove, CA Don t forget to enclose your proof of age! e-tran Senior Transportation Service Applications Rev

SCAT Application. (1) SCAT Eligibility Questionnaire Form and (2) Professional Verification Form

SCAT Application. (1) SCAT Eligibility Questionnaire Form and (2) Professional Verification Form The has two different forms and both forms must be completed and received by GTA either prior to the in-person interview, or brought to the interview: (1) SCAT Eligibility Questionnaire Form and (2) Professional