Paratransit Conditional Eligibility Assessment Form
Applicant Information
Full Name
Date of Birth
Address
Phone Number
City
ZIP Code
Disability Information
Type of Disability
Mobility Aids Used (if any)
Explain how your disability prevents use of fixed-route transit
Conditional Eligibility Assessment
List any environmental/physical barriers that affect your mobility (e.g. steep hills, lack of sidewalks)
Describe any weather conditions that may limit your travel independently
Distance you can travel independently (in blocks or miles)
Do you require the assistance of another person to travel?
Yes
No
Other Information
Other comments or relevant information
Applicant Certification
I certify that the information provided is correct.
Signature
Date