ADA Dial-A-Ride Service Application Form TYPE OF APPLICATION Date * Select Type * New Application Renew PART 1: GENERAL INFORMATION ABOUT APPLICANT Gender * Male Female First Name * Last Name * Middle Initial * Street Address * Apartment Number Nearest Cross Street to Street Address * City * State * Zip Code * Date of Birth (MM/DD/YYYY) * Home Phone * Mobile Phone Mailing address (If different from above) Mailing Address City State Zip Code Are you eligible for Medi-Cal? * Yes No If yes, please enter your Medi-Cal Number. * EMERGENCY NUMBER Please give us the name and telephone number of someone we can call in an emergency. First Name of Emergency Contact Last Name of Emergency Contact Phone of Emergency Contact Relationship of Emergency Contact Did someone help you fill out this application? Yes No If Yes, please enter their First Name Last Name Phone Number Relationship PART 2: INFORMATION ABOUT APPLICANT’S DISABILITY Please read the following statements and check the one that best describes your disability or condition. * 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. 1. What is your disability(s)? Please list all disabilities that prevent you from using fixed route bus service. * 2. How does your disability prevent you from using fixed route bus service? Please explain. * 3. Is the disability described above temporary or permanent? * Temporary Permanent I don't know If temporary, how long do you expect the disability to last? * PART 3: INFORMATION ABOUT APPLICANT’S MOBILITY AIDS 4. Please indicate below if you use any of the following mobility aids or equipment. * None Cane White Cane Crutches Walker Leg Braces Manual Wheelchair Electric Wheelchair Scooter Portable Oxygen Service Animal Other 4a. Please describe Other: 4b. If you use a wheelchair or scooter, RTA Dial-A-Ride buses may not be able to accommodate you if your wheelchair or scooter is longer than 51" or wider than 30" or if your total weight with your wheelchair is more than 800 pounds. What is the combined weight of you and your wheelchair or scooter? 4c. If you use a wheelchair or scooter, how far can you travel using your wheelchair or scooter? 0-1 block 2 blocks 3 blocks 4 blocks 5 blocks 6 blocks 7 blocks 8 blocks or more 4d. If you use a service animal, please describe your service animal. 5. Do you require the assistance of a (PCA) Personal Care Attendant (someone who assists you when traveling?) * Yes No If Yes, how do they help you? * PART 4: INFORMATION ABOUT APPLICANT’S ABILITIES 6. What form of transportation do you currently use? * Fixed route bus service Dial-A-Ride service Drive yourself Someone drives you Other 6a. If Other, please explain 7. Does your disability or condition change from day to day in a way that makes it very difficult to use the fixed route buses? * Yes No 7a. If Yes, please explain * 8. Does the weather ever keep you from using fixed route buses? * Yes No 8a. If Yes, please explain * 9. When crossing a street what do you look or listen for? * Do not cross streets without assistance Listen for traffic sounds Look for a crosswalk signal Look for traffic and cross when safe 10. Are you able to locate the appropriate fixed route bus to complete your trip? * Yes No 10a. If No, please explain * 11. How far can you travel on your own or using a mobility aid? * 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 12. Do any of these barriers prevent you from using the fixed route bus service? Check ALL that apply. * Hills Lack of curb cuts Lack of sidewalks Uneven surfaces Rough terrain Other None 12a. If Other, please explain Other 13. Do you have a vision problem that would prevent you from using the fixed route buses? * Yes No 13a. If Yes, please select all that apply and explain. * Restricted fields Legal blindness Total blindness Light sensitivity Night Blindness 13b. Please explain * 14. Are you able to independently get to and from bus stop? * Yes No Sometimes 14a. If No or Sometimes, please explain * If No or Sometimes, please explain * 15. Are you able to independently transfer between fixed route buses to reach your destination? * Yes No Sometimes 15a. If No or Sometimes, please explain * 15a. If No or Sometimes, please explain * 16. All RTA buses have a wheelchair lift or ramp and many have a "Kneeler" which lowers the height of the steps. Passengers who find the steps to be too high may enter and exit the bus using the wheelchair lift or ramp. Are you able to get on and off the fixed route bus? * Yes No 16a. If No, please explain * 17. What would you do if you found yourself at the wrong place? * Phone home Ask someone for assistance Panic Do not know Other 17a. If Other, please explain Other 18. How do you communicate your needs to the driver? * Verbal Visual Sign Unable 19. Are you able to do the following? (Check ALL that you can do.) * 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 20. Have you taken the fixed route bus independently before? * Yes No 20a. If Yes, when? * 20b. If No, why have you not taken the fixed route bus before? * 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 20c. Please explain Other 21. Do you now use fixed route buses on your own? * Yes No Sometimes 21a. If yes, please choose all that apply * I use simple direct trips I use complex trips using transfers 21b. If Yes or Sometimes, please list the routes you use. * 21b. If Yes or Sometimes, please list the routes you use. * 22. Have you ever received travel or mobility training for using the fixed route bus system? * Yes No 22a. If Yes, to and from which destination and/or route? * School Workshop Work Route Number Other 22b. Please enter Route numbers, if applicable 22c. If Other, please explain 23. Is there any additional information you would like to share regarding your disability or condition that prevents you from using the fixed route bus system? 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 Name (or Legal Guardians Name if under 18 years old) *
