ADA Transportation Eligibility Application

Part A: Personal Information

First Name M.I.Last Name

Street City State ZIP

1. Is this an apartment complex, mobile home park, or facility?YesNo

2. Name of complex or facility (if applicable)Mailing Address (if different from above)

Primary Phone Mobile Phone

Email Address Date of Birth

Gender:MaleFemalePrefer not to answer

Part B: Emergency Contact (Authorized to contact APT and to act on your behalf)

Contact Name

Phone Relationship to Applicant

Applicant’s Release (Please Initial)

I am filling out this form on behalf of the applicant.I understand the purpose of this evaluation form is to determine my eligibility for ADA Transportation service.I understand the information about my disability contained in this application will be kept confidential and shared only with professionals evaluating my eligibility.I hereby authorize my medical representative to release any and all information regarding my medical condition to All Points Transit.I understand that false or misleading information provided by me or someone acting on my behalf could result in my eligibility being denied or revoked.

Part C: Tell us about your disability or disabling health condition

1. What is the primary disability or health condition that you feel prevents you from being able to use APT’s Fixed Route Bus Service? Please be specific. Date of diagnosis or onset

2. Do you have other physical or mental health disabilities or conditions that may limit your ability to use APT’s Fixed Route Bus Service?YesNo

If yes, please explain

3. Do the effects of your disability or health condition vary from day to day?YesNo

If yes, please explain

4. Is your disability or health condition:PermanentTemporary

If you answered Temporary, please explain

Part D: Tell us your knowledge of APT’s Fixed Route Service

1. Have you used APT’s Public Bus Service?YesNo

If yes, how often do you use the public route?2. When was the last time you used the Public Bus Service?3. Which APT bus stop is closest to your home?

Are you able to get to this stop on your own?YesNo

4. Are you able to, on your own, use the internet or telephone to obtain bus information?YesNo

5. How would you describe the terrain where you live? (e.g., steep hill, flat, uneven sidewalks, no sidewalks, etc.)

6. What best describes your ability to use the APT Public Bus Service?I can use the public bus for most trips.I could use the public bus, but it would be difficult.I can use the bus, but only for specific destinations.I have never tried to use the public bus.I cannot use the public bus without a personal care attendant.I cannot use the public bus at all.

If you cannot use the public bus at all, please explain

7. Do weather conditions prevent you from using the bus? (Check all that apply)HeatColdSnow/IceRain

8. How do you currently travel? (Check all that apply)I drive myselfSomeone else drives meVan/Car ServiceTaxi/UberFixed Route BusDial-a-Ride

9. Have you ever received mobility training (i.e., has someone shown you how to ride the fixed route bus)?YesNo

10. Which of the following mobility aids or equipment do you use? (Check all that apply)NoneWhite CaneCaneScooterPower ScooterManual WheelchairPowered WheelchairCrutchesHearing DeviceOxygen TankService Animal

Other (please describe)

11. What is the farthest distance you can reasonably travel without assistance from another person? Assume level ground and no barriers or weather issues.Less than 200 feet1/4 mile (about 3 blocks)1/2 mile (about 5 blocks)3/4 mile (about 8 blocks)More than 3/4 mile

Estimated time to travel this distance (minutes)

12. Are you able to wait at a bus stop without a shelter or bench?YesNo

If yes, how long can you wait?Less than 5 minutesLess than 10 minutes10 minutes or more

13. When using ADA Transportation service, will your health condition or disability require you to travel with a personal care attendant, caregiver, or escort?YesNoSometimes

14. Do you require someone to meet you at your destination? (For example, individuals with dementia or Alzheimer’s who cannot be left alone.)YesNo

Part E: Independent Travel and Navigation Skills

Please select the answer that best describes your ability:

1. Are you able to ask for, understand, and follow directions?YesNo

2. Are you able to recognize destinations, landmarks, and bus stops?YesNo

3. Are you able to read printed information?YesNo

4. Are you able to communicate your needs?YesNo

5. Are you able to process spoken words or auditory information?YesNo

6. Are you able to cope with unexpected problems or changes to your routine?YesNo

7. Are you able to travel independently and safely through crowded and/or complex facilities?YesNo

8. Are you able to travel independently along sidewalks and other pedestrian paths?YesNo

9. Are you able to cross a busy street independently?YesNo

10. Are you able to use a telephone to make and receive calls?YesNo

Part F: General Questions

The following are general questions to help APT better serve our customers. Please answer all applicable questions to the best of your ability.

1. If you require a ramp or lift to safely travel, does your residence or living arrangement have an ADA-accessible entrance?YesNo

2. If you would like to designate a pick-up location other than your front door or main entrance, please specify (e.g., side entrance of building to the west)3. Please provide any additional information that may help APT offer you the best possible service

Part G: Applicant Certification and Signature

Important: This application must be signed. Unsigned applications will not be accepted.

I understand that the purpose of this application is to determine whether I am eligible to use All Points Transit (APT) ADA Transportation services. I certify that the information provided in this application is true and correct to the best of my knowledge. I understand that providing false or misleading information may result in denial or revocation of service. I also understand that any information I provide will be used only for the purpose of evaluating my eligibility for APT ADA Transportation services and, if approved, for the provision of those services.

Signature of Applicant or Legal Representative (type full legal name) Date Signed

If this application was completed by someone other than the applicant, that person must complete the following:

Relationship to the Applicant

First NameLast Name

Address

PhoneEmail

Organization or Agency Affiliation (if any) I have knowledge of the applicant’s disability or health condition. I am aware of how the applicant’s disability or health condition limits or prevents use of the APT Fixed Route Bus System.

Representative’s Signature (type full legal name)Date Signed

Part H: Authorization to Release Medical Information

To evaluate your request for ADA-eligible transportation services, All Points Transit must obtain information from a health care provider familiar with your condition. A Professional Verification Form will be sent to the provider you list below.

Please complete the provider’s information:

Name of Professional Title Address

Phone Fax

I authorize the above-named provider to release information to All Points Transit’s Accessible Transportation Program. I understand that this information will be used solely to determine my eligibility for services under the Americans with Disabilities Act (ADA), and will be kept secure and confidential.

Applicant Name (please print) Signature of Applicant or Legal Representative (type full legal name)

Today’s Date Applicant’s Date of Birth

Part I: Application Submission Checklist

Before submitting your application, please make sure you have:

Answered all questions related to your health condition or disability. Signed the certification in Part G. Completed and signed the Medical Release Form in Part H.

ADA Transportation Eligibility Application

Apply online or download a printable application