MINI BUS ADA PARATRANSIT ELIGIBILITY APPLICATION
PART A
Personal/Contact Information
The Mini Bus provides door-to-door Paratransit service to individuals who cannot use the regular City Link fixed
route service to make their trips. To be eligible for service, the functional limitations of an individual’s disability
must prevent regular use of fixed-route bus service. Architectural and environmental barriers such as distance,
terrain or weather do not, standing alone, form a basis for eligibility. However, consideration may be given to
the interaction of environmental conditions (terrain and weather) with the individual’s impairment related
condition.
To become eligible for service, applicants along with a qualified professional such as: physician (M.D. or D.O.),
registered nurse, physical or occupational therapist, psychiatrist, psychologist, mental health counselor,
vocational counselor, rehabilitation specialist, independent living skills trainer, or ophthalmologist must
complete and submit PART A and PART B for review within 21 days of the day the applicant first rode the Mini
Bus.
Applicants will also need to complete an Authorization Form for Disclosure of Protected Health Information
attached to Part B that will be submitted by the qualified professional.
Please Type or Print in Ink to complete application forms.
Last Name_______________________ First Name _____________________MI____
Address _________________________________________Apt. No.______________
City/Town ______________________________________State ______Zip_________
Home Phone : (____)____________ Work Phone: (_____)_________________
TTD/TTY (____)________________ Cell Phone (____)____________________
DOB ____/____/_____ E-Mail address: _________________________________
Please notify the Finney County Transit office of any change in address, phone number(s), emergency contact,
medical condition or special assistance needs.
Do you require information in an alternative format?
Braille_________Large Print_______Audio Tape_______Other:_____________
************************************************************************************************************
If someone is helping you with this application, that person must complete the following:
Name __________________________________________________________________
Address ________________________________________________________________
Home Phone (___) ___________ Work Phone (___) _________________
Emergency Contact Information:
Name _______________________________ Relationship: _____________________
Home Phone: (___) ____________________ Cell Phone: (___) _________________
Work Phone: (___) ____________________
INFORMATION ABOUT YOUR ABILITIES
1. What is the disability or health condition that prevents you from using the regular fixed-route City Link
service?
___ Certified Legally Blind
___ Loss or inability to use one or more limbs
___ Severe effects of stroke
___ Paralysis affecting mobility, speech, vision or memory
___ Severe Arthritis
___ Autoimmune Disorders, for example, Lupus or Scleroderma etc.
___ Severe cardiac and/or respiratory impairment affecting strength and/or endurance
___ Severe emotional disorder (may require an escort)
___ Developmental disabilities, for example, mental retardation, cerebral palsy, epilepsy, autism or
neurological disorder, etc.
___ Hearing loss accompanied by an inability to understand speech with/without a hearing aid, other
(please explain):
___________________________________________________________________________________
a. Is your disability permanent? ____ Yes ____ No
b. If your disability is temporary, how long do you think it will be until you’re better? # ___________Months.
c. Is there a season during the year that your disability/health condition worsens and prevents you from
traveling without help? (Check all that apply)
_____ Spring _____ Summer _____ Fall _____ Winter
2. Do you use any of the following mobility aids? Check all that apply.
____ Manual Wheelchair ____ Electric Wheelchair
____ Powered Scooter ____ Cane
____ Walker ____ White Cane
____ Service Animal ____ Crutches
____ Oxygen ____ Other (please list) _______________
3. Do changes in weather (like extreme heat, cold, wind, rain, snow and/or ice) combined with your disability or
health condition stop you from using the City Link fixed-route service? _____ Yes _____ No
If yes, explain completely. Use an additional sheet if necessary.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
4. Do you require the assistance of a personal care attendant (PCA) when you travel? (Riders must provide
their own PCA) ______ Yes _______ No ______ Sometimes
5. All Finney County Transit vehicles have wheelchair lifts (if you are unable to climb stairs, you can stand on
the lift). Would you be able to get onto and off of a regular bus without the help of another person? (The
driver operates the lift and helps with the securement system. Lifts have handrails.)
______ Yes ______ No_______ Sometimes
If you answered No or Sometimes, explain why:
________________________________________________________________________________________
6. Does your disability or health condition stop you from getting to or from a bus stop without help from another
person, for one of the following reasons? (Check all that apply.)
___Unable (not just difficult) to travel on rough or hilly terrain
___Extreme sensitivity to certain weather conditions
___Extreme fatigue due to health condition
___Unable to cross busy intersections
___ Lack of sidewalks and curb cuts at bus stop
___ Unable to locate bus stop due to a visual impairment
___ Unable to wait outside for ten (10) minutes
___ Unable to travel on ice or snow covered surfaces
___ Unable to identify correct bus in the daytime when it is light
___ Unable to identify correct bus in early morning or evening hours when it is dark
___ Other
Please explain:____________________________________________________________________
________________________________________________________________________________
7. How many blocks is your home to the nearest bus stop?__________________________
(A city block is approximately 500 feet long)
8. Indicate below how far you are able to travel without help.
___ I can get to the curb in front of my house/apartment
___ ¼ mile (3 blocks) ___ ½ mile (6 blocks) ___ ¾ mile (9 blocks)
9. After arriving at a bus stop, how long can you wait outside (not sitting) until the bus arrives?
___ 30 minutes or longer ___ 15 minutes ___ 10 minutes ___ Less than 10 minutes
If you cannot stand while waiting, why not? __________________________________
10. Are you able to perform the following functions without assistance from another person: (check all that
apply)
___ Understand and/or process information
___ Ask for or follow written or oral information, such as schedules including TDD, audio tape or voice?
___ Figure out the correct fare?
___ Follow instructions in an emergency?
___ Recognize your destination while on the bus?
___ Once you get off the bus, locate and reach your destination?
___ Cross a busy intersection?
___ Find your way between familiar locations?
___ Signal the bus driver to get off the bus at a familiar stop and then get off the bus? Assume the driver calls
all stops.
___ Grasp coins, passes, and handles?
___ Communicate addresses, destinations, and telephone numbers on request?
___ Deal with unexpected situations or unexpected changes in routine e.g., route changed due to road
construction, regular bus stop closed?
___ Go up and down steps?
11. If training for riding on the City Link fixed route service were available at no charge, do you think that you
would benefit from receiving this training?
_____ Yes _____ No
*************************************************************************************************************
I understand that the purpose of completing PART A is the first step to determine if I am eligible for Mini Bus
ADA Complementary Paratransit Service. Furthermore, I agree to have a qualified professional conduct an
independent professional assessment of my eligibility by completing PART B of the application process. I
understand that failure to participate in this assessment will result in a denial of eligibility for the Finney County
Transit Mini Bus paratransit service. I understand that Part A, Part B, and the Authorization Form for Disclosure
of Protected Health Information attached to Part B must be submitted to complete the application review. In
addition, I authorize the qualified healthcare professional completing Part B on my behalf to release this
information to Finney County Transit for their review as well as any supporting or other pertinent information
about my health or medical condition to assist Finney County Transit staff in determining eligibility for Mini Bus
service. I understand that upon receipt of Part A submitted by me or a representative on my behalf, and Part B
by a qualified professional conducting the independent professional assessment will begin the 21 calendar day
application review period by the Finney County Transit. Furthermore, I understand that the Finney County
Transit may need to contact me or a representative on my behalf regarding my application as well as possibly
the qualified professional completing Part B to obtain more information.
I certify by my signature that I have been truthful in answering all questions in this application, and that the
information I have provided is correct. I understand that providing false information could result in denial of
service.
_____________________________________________________ ___________________
Applicant’s Signature Date
If you assisted the applicant to complete this form, sign below:
_____________________________________________________ ___________________
Signature Date
(to print application, right click on the document and click print)