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Is your disability permanent? _ yes no <br />If you indicated no, what is the expected duration? <br />Please select the category that best descibes your situation: <br />C1 <br />_ 1 am unable to use ADA accessible buses on the fixed route service as I have a physical, <br />mental or visual disability or impairment preventing me from using the Hele On bus <br />independently. I have trouble (please check all that apply): <br />_ boarding/disembarking the bus <br />identifying the correct bus <br />_ riding due to grasping disability (e.g. unable to grasp/handle coins to pay fare, hold <br />on to handles/railings) <br />riding due to balance issues (e.g. unable to keep balance while seated on a moving <br />vehicle) <br />_ understanding or processing information necessary to make decisions during the trip <br />— other (please explain): <br />am able to use ADA accessible buses on the fixed route service, but my bus slop is not <br />accessible due to the physical characteristics of the stop. <br />C2 Please indicate location of stop and what barriers prevent your accessibility: <br />C3 <br />I am able to use ADA accessible buses on the fixed route service, but I have an <br />impairment -related condition preventing me from getting to and/or from the nearest bus <br />stop and (please check the circumstance that applies): <br />I am unable to travel to the nearest bus stop. <br />If this is checked, how far are you able to travel on your own or with the assistance of <br />your mobility device? (1 block = 500 feet) <br />I am unable to wait at the bus stop for the following reason(s): <br />I am prevented from traveling to and/or from boarding location due to the following <br />reason(s): <br />inability to negotiatehilly terrain <br />extreme sensitivity of climatic conditions <br />allergic/envirnonmental sensitivities <br />night -blindness <br />inability to cross busy intersections <br />other (please explain): <br />Signature: Date: <br />Name of Person if Other Than Applicant Completing Form: <br />Relationship: Contact Phone: <br />IMPORTANT! DO NOT MAILI CALL 9M-8343 FOR YOUR INTERVIEW AND IN-PERSON ASSESSMENT SCHEDULING <br />You must bring in valid photo identification and this completed ADA paratransit service <br />application to your in-person assessment appointment. <br />Rev 5/2016 <br />