Aspen - Ada Complementary Paratransit Application Form

Aspen - Ada Complementary Paratransit Application Form - Rfta Page 2

ASPEN - PARATRANSIT ELIGIBILITY APPLICATION FORM

The following information is being gathered by the Roaring Fork Transit Agency. It will be used only

for the provision of transportation services to the applicant. This information will not be shared with

any other organization, except for the purpose of providing transportation services to the applicant.

Please include a completed medical verification form with your application.

NAME: _____________________________________________________

STREET ADDRESS:

__________________________________________

MAILING ADDRESS: __________________________________________

(If Different) __________________________________________________

TELEPHONE: (Home)_________________ (Work)______________________

DATE OF BIRTH: _______________________

What disability prevents you from using existing services?_____________________________

___________________________________________________________________________

Is this condition temporary? ____Yes ____No

If temporary, what is the expected recovery date? __/__/__

How does this disability prevent you from using existing transit services? (Please explain completely.

Use another sheet if necessary.)

Are there other effects of your disability of which RFTA needs to be aware?

Which of the following aids do you use? (Check all that apply)

___Cane ___Crutches ___Manual Wheelchair ___Electric Wheelchair ___Oxygen

___Powered Scooter ___Guide Dog ___Personal Care Attendant ___Other? ________

Do you require a Personal Care Attendant when you travel using transit? ___Yes ___No

Can you travel 200 feet without the assistance of another person? ___Yes ___No

Can you travel ¾ mile without the assistance of another person? ___Yes ___No

Aspen - Ada Complementary Paratransit Application Form - Rfta Page 2