Paratransit Eligibility Application Form
Applicant Information
Full Name
Date of Birth
Street Address
City
ZIP Code
Phone
Email
Disability & Mobility Information
Describe your disability and explain why it prevents you from using regular fixed-route transit:
Do you use any mobility aids or devices? List all that apply:
Functional Ability
Are there any circumstances or conditions that affect your ability to travel independently?
Emergency Contact
Name
Relationship
Phone
Healthcare Professional Information
Provider Name
Phone
Provider Address
Applicant Signature
Date