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Paratransit Application Form

Please note that any information given on this application will be kept confidential and shared only with professionals involved in providing the paratransit service on an as needed basis. THIS APPLICATION WILL BE ACCEPTED AT ANY ADA PARATRANSIT PROVIDER IN THE STATE OF CONNECTICUT.


A. Personal Information













B. Current Residence






















C. Mailing Address (if different from residence)


















D. Contact Info












E. Emergency Contact
















F. If someone assisted you in completing this form, please give the following information
















G. General Information













If yes:








H. Information About Your Disability









Manual Wheelchair*
Scooter*
Powered Wheelchair*
Cane
Crutches
Walker
Communication Device
Oxygen Tank
Oxygen Compressor
Respirator
Service Animal
Medical Equipment
Other, explain below




*The term wheelchair refers to any three or more wheeled device utilized which is usable indoors. We will be able to accommodate a wheelchair if (1) the lift and vehicle can physically accommodate it and (2) if it is consistent with legitimate safety requirements. Legitimate safety requirements include but are not limited to such circumstances as a wheelchair of such size that it would block an aisle, or would interfere with the safe evacuation of passengers in an emergency.
















I. Public Bus Service Experience














J. Functional Ability



























K. Barriers



Lack of curb cuts
Busy street I must cross
No sidewalks
Steep hills
No crosswalk light
Sidewalk in poor condition
Other, describe below








L. Authorization to obtain physician or other professional verification


In order to evaluate your request, it may be necessary to contact your physician or other professional to confirm the information you have provided. Please complete the following information.



























I understand that the purpose of this application is to determine if there are times when I cannot use the public bus service and must therefore use ADA paratransit services. I certify that to the best of my knowledge, the information in this application is true and correct. I understand that providing false or misleading information may result in a reevaluation of my eligibility.