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HELE-ON KAKO'O PARATRANSIT APPLICATION <br />After completing this application, please call the County of Hawaii Mass Transit Authority to <br />schedule your in-person functional ability assessment at (808) 961-8343. <br />1. PERSONAL INFORMATION - please print clearly M.I. <br />Last Name: First: <br />_Female ___Male Date of Birth (MM/DD/YYYY): _J ---J <br />HOME/PHYSICAL ADDRESS: ZIP: <br />Street City: <br />Primary Phone: (._____) Alternate Phone: ( ) - <br />MAILING ADDRESS (If different from above): ZIP: <br />Street: City: <br />EMERGENCY CONTACT INFORMATION (required): <br />Name: Relationship: <br />Primary Phone: ( ) Alternate Phone: (_) <br />2. MOBILITY INFORMATION - please pdnt clearly <br />Please state your disability: <br />Which of the following mobility aids or equipment do you use? (check all that apply) <br />o *Power wheelchair Length (inches): Width (inches): <br />❑ *Manual wheelchair Length (inches)* Width (inches): <br />o Scooter Length (Inches): Width (inches): <br />❑ Walker <br />❑ Crutches <br />❑ Portable oxygen tank <br />o Cane <br />❑ Service animal <br />❑ Other (please explain): <br />❑ None <br />*The maximum weight capacity of the vehicle ramp is a combined total weight of 600 <br />pounds. If you exceed this limit, you must be able to board the vehicle separately from your <br />mobility device. <br />*Vehicle ramp width and length may vary from vehicle to vehicle; however, the minimum <br />dimensions of any vehicle ramp is 30" (wide) and 48" (length). <br />Do you require the use of a personal care attendant* (PCA)? —Yes — Noon Hele <br />*Your PCA must be registered with the County of Hawai'i MTA to accompany you <br />On Kako'o at no charge, subject to the rules and regulations regarding PCA. If you checked <br />yes, please complete the following: <br />Name of PCA: Phone: <br />PCA's address: <br />(continued on next page) <br />Rev 5/2016 <br />