Rider Eligibility Commando Rd. W., Suite 215, Everett, WA 98204

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1 Dear Applicant, The Americans with Disabilities Act (ADA) of 1990 is federal legislation that supports the rights of people with disabilities to participate more fully in community life. As required by the ADA, all Community and Everett Transit buses and facilities are fully accessible for people with disabilities. The regular bus service is meant to be everyone s first choice for public transportation. For ease of entry, all buses kneel (lower to ground level), or have ramps and/or lifts. In addition, other accommodations such as wheelchair securement areas, audible and visual stop announcements, and free training to learn how to use the bus, make regular bus service possible for most people with disabilities. If you do not use the regular fixed route bus system because you are not sure how, free transit instruction is available to meet your individual needs, including wheelchair lift/ramp training. This free training is open to seniors, people with disabilities and limited English speaking persons. Call for more information. Because the regular bus service is accessible, having a disability does not, by itself, qualify you for paratransit service. Eligibility is not a medical decision, but rather based on your functional ability to use the regular bus. If the effects of your disability prevent you from getting to/from a bus stop, waiting for a bus, getting on/off a bus, or navigating the bus system, you may be eligible for paratransit service. Eligibility determinations are based upon the limitations caused by your disability and will be tailored to your individual abilities. You may qualify for partial or full service. Paratransit service is similar to the regular bus in fare structure, days, hours, and service area. Our service is available within 3/4 mile of the regular, fixed-route bus route, on the same days and during the same hours the regular bus service is offered. (over) Eligibility determination provided by Senior Services of Snohomish County Commando Rd. W., Suite 215, Everett, WA FAX Rev. August 1, 2015

2 We may need specific information about the effects of your disability. After you submit your application, we may request information from your listed provider(s) and/or ask you to participate in an in-person functional assessment. Your application will not be considered complete until all requested information is provided to us. Once we have received all of the necessary information, an eligibility determination will be made within 21 days. You will be notified by mail of the decision. Please note that your age, being new to the area, being unfamiliar with the regular bus system, distance from bus service, language barriers, your inability to carry packages, and/or your ability to drive are not disabilities. Nor can convenience or personal comfort be considered when determining ADA paratransit eligibility. If you feel that, due to the effects of your disability, you are unable to successfully travel using the regular bus, some or all of the time, please complete the application form. Respond to all questions and note that signatures are required on pages 5 and 6. Incomplete applications may be returned. Mail the completed and signed application, and any appropriate or supporting paperwork, to: Rider Eligibility Commando Rd. W., Suite 215 Everett, WA Please contact Customer Service, at , with any questions. Sincerely, Deborah Perry ADA Eligibility Specialist Eligibility determination provided by Senior Services of Snohomish County Commando Rd. W., Suite 215, Everett, WA FAX Rev. August 1, 2015

3 DART USE ONLY LAST NAME FIRST NAME INITIAL ADA Code Temp Duration INC / DEN / CERT Date Other Agency ACS Date Status Funding Code MV Due By NEW RECERT CLIENT # E T Paratransit Application for Dial a Ride (DART) and Everett Para Transit This application is exclusively for residents of Snohomish County, Washington. 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 1 Rev. August 1, 2015

4 QUALIFYING DISABILITY (please print clearly) 1. What is the name of 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 2 Rev. August 1, 2015

5 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 Everett Para Transit Bicycle Metro Transit Bus Access 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? 3 Rev. August 1, 2015

6 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 paratransit bus while drivers are assisting other customers. You understand that you must provide your own PCA as our 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? 4 Rev. August 1, 2015

7 APPLICANT S CERTIFICATION (please write clearly) DART and Everett Para Transit follow 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 5 Rev. August 1, 2015

8 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 us, 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 6 Rev. August 1, 2015