| (to print application, right click on the document and click print) Finney County Transit SPECIAL ACCOMMODATIONS APPLICATION PART I - GENERAL INFORMATION Last Name:_______________________________ First Name:__________________________ MI:______ Street Address:__________________________________________________________ Apt. # ________ City:___________________________ State: ________________________ Zip:____________________ Telephone: _______________ Date of Birth:____________ Social Security #:_______________________ If someone assisted you in completing this form, please identify them below: Name:______________________________________________ Phone: ___________________________ Do you need to have information given to you in any of the following ways (check all that apply)? Spanish Large Print Audio Tape Braille Other: Please give us the name and telephone number of someone we can call in an emergency: Name:______________________________ Phone:____________________ Relationship:_____________ PART II - APPLICANT’S CERTIFICATION If you are applying for the Half-Fare Discount Card as a Senior Citizen or as a Medicare Cardholder for City Link fixed route, please complete PARTS I and II only. If you are applying due to disability reasons or are interested in a Paratransit Card for Mini Bus call and demand, please complete the entire application. ____ I am over the age of 60 years. Photo identification required for verification. ____ I am a Medicare Cardholder. Photocopy of the Medicare Card required for verification. ____ I have a disability but can use the City Link route bus service some or all the time. ____ I have a disability and due to my cognitive and/or mobility impairments cannot use the City Link route
I understand the purpose of this evaluation form is to determine my eligibility for the Paratransit or the Half-Fare Discounted service. I understand the information about my disability contained in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility. I certify that, to the best of my knowledge, the information in this evaluation form is true and correct. I understand that providing false or misleading information could result in my eligibility status being re-examined. Applicant’s signature: _______________________________________________ Date:_______________ PART III - INFORMATION ABOUT THE APPLICANT’S DISABILITY What type(s) of disabilities limit your use of the City Link bus services (circle all that apply)? ____ Physical disability ____ Visual impairment/blindness ____ Developmental disability ____ Mental illness ____ Other ____ None Please describe your disability in more detail: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Is the disability described above temporary or permanent? ____ Temporary, I expect it to last for another ________months ____ Permanent ____ I don’t know Please indicate below if you use any of the following mobility aids or equipment (chck all that apply). ____ Cane ____ Long White Cane ____ Leg Braces ____ Crutches ____ Walker ____ Picture Board ____ Alphabet Board ____ Manual Wheelchair ____ Power Wheelchair ____ Powered Scooter ____ Service Animal (describe): ________________________________ ____ I Do Not use any of the above Note: We may not be able to accommodate you if your wheelchair/scooter is longer than 48” or wider than 32” or if your total weight with your wheelchair is more than 600 pounds. Do you require the assistance of a (PCA) Personal Care Attendant (someone who assists you with daily life functions)? YES____ I need assistance when I travel with: ____ Mobility ____ Reading ____ Eating ____ Transfers ____ Medication ____ Other: _____________________________________________________________________________ NO____ Due to your disability, are you currently receiving financial assistance from Medicaid, SSI, Social Security Disability, other; and how much?_________________________________________________________ PART IV - QUESTIONS ABOUT USING FINNEY COUNTY TRANSIT (FIT) BUSES Have you ever used the Mini Bus? ____ YES, I typically use the Mini buses ________ times a week ____ YES, I used to but stopped because___________________________________________ ____ NO Is there something that might help you ride the buses (check all that apply)? ____YES, route and schedule information ____YES, learning to use the buses ____YES, communication aide ____YES, if bus stops were closer to where I need them Can you ask for and follow written or oral instructions to use the Mini Bus? ____ YES ____ NO ____ SOMETIMES ____ I don’t know because I have never tried to use the buses. Using a mobility aide or on your own, how far can you travel? ____ I cannot travel outside my house/apartment ____ I can get to the curb in front of my house/apartment ____ I can travel up to 3 blocks (1/4 mile) ____ I can travel up to 6 blocks (1/2 mile) ____ I can travel up to 9 blocks (3/4 mile) Are you able to get to and from bus stops on your own? ____ YES ____ NO ____ SOMETIMES ____ I don’t know because I have not tried Can you get on and off a Mini Bus? (Note all of the paratransit and route buses have wheelchair lifts. Passengers who find the steps to be too high may enter and exit the bus by standing on the lift. ____ YES ____ NO ____ SOMETIMES ____ I don’t know because I have never tried. If you are able to get on and off a Mini Bus, can you get to a seat or wheelchair position by yourself and ride the bus? ____ YES ____ NO ____ SOMETIMES ____ I don’t know because I have never tried. If you are able to get on and off a Mini Bus, do you know where to get off the bus or can you find out by yourself. ____ YES ____ NO ____ SOMETIMES ____ I don’t know because I have never tried. Are there any other conditions which limit your ability to use the Mini Bus? ____ YES (Please describe them below): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____NO PART V - CURRENT TRAVEL INFORMATION Please list the three trips that you will make most frequently. From: To: (Place and Address) (1) ____________________________________ ________________________________________ (2) ____________________________________ ________________________________________ (3) ____________________________________ ________________________________________ Have you had any personal instruction on how to use the City Link fixed route system? ____NO, I have not received any personal instruction. ____YES, I received personal instruction through an agency. (Name of agency):___________________________________________________ ____ YES, I received personal instruction from a friend/relative Indicate below all of the skills you learned: ____ To travel to and from bus stops ____ To cross streets ____ To ride on the following routes (please list them): Route # ____ Route # ____ Route # ____ ____ Reading bus schedules and planning trips ____ Other: ________________________________________________________ MEDICAL VERIFICATION FOR PARATRANSIT APPLICATIONS ONLY (To be completed by a licensed physician or social service representative) The Americans with Disabilities Act of 1990 (ADA) requires Finney County Transit to provide transportation services to anyone with a disability that is traveling in an area served by our buses. The applicant who has asked you to review and sign this form is applying to Finney County Transit to be considered eligible for special accommodations. ADA paratransit service is intended only for persons with mobility and/or cognitive impairments that limit their ability to use the route system. The application form is intended to determine if and why the applicant requires paratransit (door-to-door) service. Signature: ____________________________________________ Date: ___________________ Print Name and Title: ____________________________________________________________ Business Address: ______________________________________________________________ ______________________________________________________________ City/State: ___________________________________________ Zip Code: _________________ Telephone Number: ( )___________________________________ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (For Office Use Only) _______________________________________________________________________________________ Card Issued Date Issued Initials |