TYPE OF APPLICATION

New Application Renew

PART 1: GENERAL INFORMATION ABOUT APPLICANT

Male Female

Mailing address (If different from above)

Yes No

EMERGENCY NUMBER
Please give us the name and telephone number of someone we can call in an emergency.

Yes No

PART 2: INFORMATION ABOUT APPLICANT’S DISABILITY

I have a temporary disability and will only need Dial-A-Ride until I recover. I have a visual disability which prevents me from using the city bus. I have difficulty remembering all of the things I have to do when using the city bus. I can use the city bus for some trips but not others. I have a disability(s) that cause me to have good day(s) and bad day(s). I am able to ride the city bus independently. I believe I can learn to ride the city bus if someone taught me. I can never use the city bus myself.
Temporary Permanent I don't know

PART 3: INFORMATION ABOUT APPLICANT’S MOBILITY AIDS

None Cane White Cane Crutches Walker Leg Braces Manual Wheelchair Electric Wheelchair Scooter Portable Oxygen Service Animal Other
0-1 block 2 blocks 3 blocks 4 blocks 5 blocks 6 blocks 7 blocks 8 blocks or more
Yes No

PART 4: INFORMATION ABOUT APPLICANT’S ABILITIES

Fixed route bus service Dial-A-Ride service Drive yourself Someone drives you Other
Yes No
Yes No
Do not cross streets without assistance Listen for traffic sounds Look for a crosswalk signal Look for traffic and cross when safe
Yes No
I cannot travel outside my house I can get to the curb of my house I can travel up to 1 block I can travel up to 2 blocks I can travel up to 3 blocks I can travel up to 4 blocks I can travel up to 5 blocks I can travel up to 6 blocks I can travel up to 7 blocks I can travel up to 8 blocks
Hills Lack of curb cuts Lack of sidewalks Uneven surfaces Rough terrain Other None
Yes No
Restricted fields Legal blindness Total blindness Light sensitivity Night Blindness
Yes No Sometimes
Yes No Sometimes
Yes No
Phone home Ask someone for assistance Panic Do not know Other
Verbal Visual Sign Unable
Ask for, understand, and follow directions Tell what time it is Recognize a destination landmark Use a telephone to make and receive calls Give address and telephone number None

PART 5: QUESTIONS ABOUT USING FIXED ROUTE BUSES

Yes No
I do not know how to get bus information For cognitive reasons, unable to navigate the bus system Unable to read information (language barrier excluded) Cannot get to the bus stop Other
Yes No Sometimes
I use simple direct trips I use complex trips using transfers
Yes No
School Workshop Work Route Number Other

RELEASE OF INFORMATION

By signing this form I understand I am giving consent for Riverside Transit Agency to use and disclose my protected health information for the following purpose and activities:
1. To transfer information to medical professionals for review, transportation providers and mobility services.
2. Permission to contact my healthcare provider to verify my disability and treatment plan for purposes of paratransit eligibility.
3. The information provided is true and correct to the best of my knowledge. I understand that falsification of information will result in denial of service.
RTA appreciates your cooperation in this process and assures you that your protected health information will be managed strictly confidential.

CHECKED AND AGREED