Paratransit Application Form | Connecticut ADA Paratransit Resource Center

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

1. Date of Birth:

2. Last Name (Required):

3. First Name (Required):

4. Salutation:

B. Current Residence

5. Street Address (Required):

6. Building:

7. Apartment:

8. Room:

9. City (Required):

10. State (Required):

11. Zip (Required):

12. Is this residence:

13. Is this a temporary residence?

C. Mailing Address (if different from residence)

14. Street Address or P.O. Box:

15. Building:

16. Apartment:

17. Room:

18. City:

19. State:

20. Zip:

D. Contact Info

21. Primary Phone (Required):

22. Alternate Phone:

23. TDD or Relay Number:

24. Email Address (Required):

E. Emergency Contact

25. Last Name:

26. First Name:

27. Relationship:

28. Agency, if applicable:

29. Primary Phone:

30. Alternate Phone:

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

31. Last Name:

32. First Name:

33. Relationship:

34. Agency, if applicable:

35. Primary Phone:

36. Alternate Phone:

G. General Information

37. Do you need ADA service information in an accessible format?

38. If "yes", please indicate which format would be helpful:

39. Other accessible formats:

40. Are you certified for ADA paratransit services by another service provider or transit agency?

If yes:
41. Name of Service Provider:

42. State:

43. ID Number, if applicable:

H. Information About Your Disability

44. Please list by name what disabilities or health related conditions prevent you from using the public bus service:

45. Explain how your disabilities or health related conditions prevent you from independently using the public bus service?

46. Do you use any of the following when you travel?

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

47. Other travel options:

*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.

48. Is the disability or health related condition you describe:

49. If temporary, expected to last how many months?

50. Does your health condition or disability change from day to day in a way that affects your ability to use the public bus service?

51. If "Yes" or "Sometimes", Please explain:

52. Are there times when someone accompanies you when you travel?

I. Public Bus Service Experience

53. Do you ride the public bus? Have you ever ridden the public bus?

54. If yes, how often and to what locations?

55. If no, why don’t you currently ride the public bus?

56. Travel training is a free service that teaches people how to use the public bus. Would you like more information about this service?

J. Functional Ability

57. Can you find your way to a public bus stop if someone shows you once?

58. How far can you walk (using a mobility aid if necessary)?

59. Can you walk up/down a gradual hill?

60. Can you see/detect curbs, ramps and other drop off areas?

61. How long can you stand and wait at a public bus stop?

62. Can you get on and off a public bus?

63. If "No" or "Sometimes", Please explain:

64. Can you ask for, understand, and follow travel directions?

65. If "No" or "Sometimes", Please explain:

K. Barriers

66. What barriers in the environment would make it difficult for you to use the public bus service?

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

67. Other barriers:

68. Explain why the conditions you indicated make it difficult to use the public bus service:

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.

69. Profession:

70. Professional's Name:

71. Agency:

72. Office Address:

73. City:

74. State:

75. Zip:

76. Phone:

77. Office Fax:

78. Applicant's Name:

79. Date of Birth:

80. Applicant agrees to share the application information with other service providers within the State of Connecticut

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.