PARATRANSIT ELIGIBILITY APPLICATION

PARATRANSIT ELIGIBILITY APPLICATION
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PLEASE READ THE FOLLOWING BEFORE YOU START THE APPLICATION PROCESS

ADA Paratransit is a shared ride, advanced reservation, origin to destination service for individuals who, because of their disability, are unable to use Skagit Transit’s Fixed Route transit service for some or all of their trip(s).

ADA Paratransit service is not appropriate for everyone. Fixed Route bus service is intended to be all passenger’s first choice for public transportation. Fixed Route buses have low entry steps and are equipped with ramps or lifts for wheelchair access and for those who cannot step up or down. Other accommodations, such as wheelchair securement areas, bus stop announcements, and free travel training to learn how to navigate our system, make using Skagit Transit’s Fixed Route transit service the first choice for many people with disabilities.

Having a disability does not automatically qualify you for Paratransit eligibility. Eligibility is not a medical decision or a service that your medical professional can prescribe for you. Age, new to the area, lack of experience riding Fixed Route, lack of bus service near you, inability to carry groceries or packages, and/or inability to drive are not disabilities. Situations like these will not be used to determine your eligibility for Paratransit.

Paratransit eligibility is based on your functional ability to use Skagit Transit’s Fixed Route bus service. If the effects of your disability prevent you from traveling to a bus stop, riding a ramp equipped bus, and/or getting off the bus to and from your destination, you may be eligible for ADA Paratransit service. Eligibility determinations are made based upon the Fixed Route bus riding limitations caused by your disability(ies) and are tailored to your individual abilities. You may qualify for temporary, partial (conditional) or full (unconditional) service.

Please be aware that Skagit Transit Paratransit cannot transport individuals with medical conditions or symptoms for which a higher level of care is needed for transport. Skagit Transit Paratransit will not transport anyone whose condition changes if it appears to prevent him or her from being safely transported.

After we receive your completed application, you may be required to visit Skagit Station for an in-person assessment. There is no cost for the assessment, and transportation will be provided if needed. An eligibility representative will contact you after the completed application has been received to set up an appointment.
Thank you for your interest in Skagit Transit’s Paratransit Service!

All persons seeking eligibility for Paratransit service must complete the eligibility process that begins with submitting this application form and may include an in-person assessment. For more information, please refer to the ADA Paratransit user’s guide on our website- www.skagittransit.org, pick up a copy at Skagit Station, or request a copy by mail. If you have any questions or need assistance completing this application form, we are happy to help. Please contact our travel trainer at (360) 757-9191 for assistance.
INSTRUCTIONS

Before submitting the application form, please:

1. Read Skagit Transit’s ADA Paratransit user’s guide

2. Complete all sections of this application form

3. Ensure the applicant or, if applicable, Legal Guardian or Power of Attorney signs the application. A signature is required before an application will be processed

*The parent or legal guardian of a minor is required to sign the application

ADDITIONAL ATTACHMENTS REQUIRED FOR A LEGAL GUARDIAN OR POA

- Please provide copies of current Letters of Guardianship and the Order Appointing Guardian document from the court

- Power of Attorney paperwork must include current documentation that grants the POA the right to sign a medical release form on behalf of the applicant

Questions? Please refer to Paratransit User Guide, call 360-757-9191 or email: Eligibility@skagittransit.org

Your application for service is not complete until all required information is provided to Skagit Transit, and you have completed any required in-person assessments.

An incomplete application will not be processed.
Applicant Information
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Mobile Phone Number
Primary Language
Email Address
example@example.com
Primary Pickup Location

Street Address

Apartment / Unit

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Apartment / Unit

CityState / Province

Postal / Zip Code
Emergency Contact Information

Name

Phone Number

Relationship to ApplicantState / Province

Postal / Zip Code
Disability or Condition

Answer all of the following questions. To avoid delays, provide complete and detailed answers. A signature is required at the end of this form. Your eligibility for Skagit Transit Paratransit service will be based on whether your disability or condition prevents you from using fixed route bus service as described in the Americans with Disabilities Act (ADA).
Please list all specific disabilities or conditions that would prevent you from using Fixed Route bus service
Is your disability or condition temporary?

NoYes
If Yes, how long will it last?
Does your disability or condition vary from day to day?

NoYes
If Yes, please explain how your disability or condition varies daily:
Does your disability or condition prevent or limit your ability to travel by yourself on public transit?

NoYes
If "Yes", please explain how your condition may prevent or limit your ability to travel by yourself:
It may be hard for our Paratransit vehicle to reach your pickup location if there are steep driveways, narrow roads, or no place to turnaround. This will not affect your eligibility, but we need to know if access could be a problem.

NoYes
If access to your pickup location could be difficult, please explain:
Ability Checklist

Please select the appropriate answer for each statement
I am able to complete my usual daily activities.

NoYesSometimes
I walk slowly.

NoYesSometimes
I can grip railings and handles.

NoYesSometimes
I am able to handle coins and tickets.

NoYesSometimes
I know and can communicate my address and phone number.

NoYesSometimes
I can recognize locations and landmarks.

NoYesSometimes
I can deal with unexpected situations.

NoYesSometimes
I can ask for, understand, and follow directions.

NoYesSometimes
I can cross busy streets.

NoYesSometimes
I can travel where the ground is not level or is rough.

NoYesSometimes
I can travel when there is snow and ice.

NoYesSometimes
I can travel in very hot weather.

NoYesSometimes
I can travel in darkness or low light.

NoYesSometimes
I can climb three (3) steps.

NoYesSometimes
I can travel if someone has shown me the way.

NoYesSometimes
I can travel from my front door to the curb.

NoYesSometimes
Please explain any "No" answers:
Condition Checklist
Please check all that apply to you

Balance ProblemsLimiting Breathing ConditionBrain InjuryMental IllnessFractureSignificant Limitation of ActivityDegenerative DiseaseSurgery RehabilitationAmputationDevelopmental DisabilityAssistance RequiredHearing ImpairedCognitive DisabilityParalysisDementia / AlzheimersSeizuresNon-VerbalSight Impaired
Balance Problems- Please Explain
Limiting Breathing Condition- Please Explain
Brain Injury Please- Explain
Significant Limitation of Activity- Please Explain
Degenerative Disease- Please Explain
Mental Illness Please Explain
Fracture Please Explain
Paralysis- Please Explain
Mobility Aids
When you travel outside your home what mobility aids do you use? Check all that apply

NonePowered wheelchairCaneManual wheelchairWhite canePowered scooterWalkerPersonal Care AttendantPortable OxygenService animalOther (please specify)
Wheelchair or Scooter Information
If you use a wheelchair or scooter answer the following questions:

What is the size of your wheelchair or scooter?
Width (inches)
Length (inches)
Is the combined weight of you and your wheelchair or scooter more than 600 pounds?

NoYes
If Yes, how much is your combined weight?
Don’t know your combined weight?

No, I do not know the combined weight of my self and my mobility device.
Travel Abilities
How far can you travel independently (walking or using your mobility aids?
If you were waiting for a ride could you STAND for 10 minutes?:

NoYes
If you were waiting for a ride could you SIT for 10 minutes?:

NoYes
Do you currently use Fixed Route bus service?

YesNo
If No, why have you not used Fixed Route bus service? Check all that apply:

I have never tried riding Fixed RouteI need someone to show me how to ride the busI have difficulty getting on and off the busI have difficulty recognizing bus stopsI have difficulty traveling to and from the bus stopOther
Communications from Skagit Transit
Skagit Transit can provide you with automated alerts regarding your scheduled rides. Please check the box of any alerts you would like to receive:
1. Reminder the night before the scheduled ride:

TextEmailVoicemail
2. Trip booking confirmation:

TextEmail
3. Trip cancel confirmation:

TextEmail
4. Vehicle is approximately 5 minutes away:

TextEmailVoicemail
5. When your vehicle arrives:

TextEmail
Email address to receive alerts
example@example.com
Cell phone number to receive alerts
Cell Phone Number
Phone number to receive voicemail alerts
Voicemail Phone Number
Additional Information
Please list anything else you want us to know about your disability, condition, or abilities. Also list any concerns you have about riding the bus
Professional Verification and Release of Information
Please provide contact information for at least one professional care provider who can provide us with relevant details about your disability or condition.
Name
Profession
Address

Street Address

Suite

CityState / Province

Postal / Zip Code
Phone Number
Phone Number
Fax Number
Name
Profession
Address

Street Address

Suite

CityState / Province

Postal / Zip Code
Phone Number
Phone Number
Fax Number
It is assumed that you or a representative of your care facility will schedule Paratransit ride requests on your behalf. Please list the names of additional people that you authorize to schedule rides on your behalf.
Authorized Person #1

First NameLast Name
Authorized Person #2

First NameLast Name
Authorized Person #3

First NameLast Name
Facility
This document authorizes the following person(s) to schedule Paratransit trips:
Medical Information Release & Declaration
I,
Your name here
authorize the above provider(s), and their office staff, to provide information to Skagit Transit about my functional abilities and medical diagnoses in order to verify my eligibility for paratransit service. I understand this release expires one year from today. I also may revoke this release any time by notifying Skagit Transit in writing.

I understand that eligibility for paratransit service is governed by the Americans with Disabilities Act (ADA) and is for people whose disability or condition prevents them from using fixed route bus service.

I understand that giving false information is against the law (RCW 9A.72.085 and RCW 40.16.030) and could result in losing access to paratransit services.

I understand that Skagit Transit may ask me to participate in a capability assessment or ask for a professional verification of my capabilities.

I understand that Skagit Transit will not use the information I provide for any purpose other than determining my eligibility or providing me with service and will keep it confidential and will not share it without my written permission.

I understand that filling out and submitting this application does not guarantee paratransit service; service is subject to eligibility based on location (address) and ability to access fixed route bus service.
Applicant E-Signature (Please sign to the best of your abilities)
If this application is being filled out for someone else, please complete the following fields:
Name of person assisting with application
Assisting person E-Signature (Please sign to the best of your abilities)
Relationship to Applicant / Representative of Facility:
Phone Number
Phone Number
Date

MonthDayYear
PLEASE NOTE:

Skagit Transit cannot process incomplete applications. Please make sure you have completed this application as fully as possible. Thank you!
Should be Empty:

PARATRANSIT ELIGIBILITY APPLICATION

Applicant Information

Disability or Condition

Ability Checklist

Condition Checklist

Mobility Aids

Wheelchair or Scooter Information

Travel Abilities

Communications from Skagit Transit

Additional Information

Professional Verification and Release of Information

Medical Information Release & Declaration