Paratransit Service by nyut545e2


									                                    Please mail this form to:                     Applicant Information
                                                                                  Please print

      C-VAN                                C-VAN
                                           PO Box 2529
                                                                                  Last Name       First Name   Initial
                                           Vancouver, WA 98668-2529               ___________________________________
                                                                                  Residence Address            Apt. #

Paratransit Service                 All C-VAN printed materials are availa-       ___________________________________
                                    ble in large print format. Please call        City                State     Zip
  Pre-application for Eligibility
                                    (360) 695-0123.                               ___________________________________
                                                                                  Mailing Address (if different)
                                    Please make sure you have answered all        ___________________________________
                                    the questions and have completed the          City                State     Zip
Please complete requested           Applicant Information section BEFORE
  information on all four           mailing this pre-application.                 Daytime Phone          TTY Number
  pages of this document                                                          ___________/____________/___________
 and mail to this address.          C-TRAN Contact Information
                                                                                  Date of Birth
                                    C-VAN Paratransit Services   (360) 695-8918
                                    Passenger Service Office     (360) 695-0123   Authorized Representative
                                                                                  Complete only if applicant is under age 18 or phys-
                                    Web Site           
                                                                                  ically or cognitively unable to sign documents.
                                    C-TRAN Employment Info       (360) 906-7491
                                                                                  Last Name       First Name   Initial
                                                                                  Daytime Phone          TTY Number
                                                                                  Relationship to Applicant / (360)-695-0123          (360) 695-0123 /        ____________________________________
       TTY: (360)-695-2760                       TTY: (360) 695-2760              Signature
Many people with disabilities can use                  1. Independent Travel                               If you checked No to all three questions, you
C-TRAN’s regular lift-equipped and kneeling              Do you have a cognitive or physical disabili-     are not likely eligible for C-TRAN’s C-VAN
buses.                                                   ty that, some or all of the time, prevents you    paratransit service. You need not complete
                                                         from getting on, riding, or getting off the       the rest of this application.
For those with disabilities that prevent use of          bus by yourself without the help of another
the regular bus system, C-TRAN offers                    person?
C-VAN paratransit bus service, a comparable                                                                A. Personal Care Attendant
                                                                                                                A personal care attendant is someone as-
curb-to-curb, reservation based service. This                Yes.
                                                                                                                sisting you on a regular basis with daily
program complies with the Americans with                     No. This does not apply to me.                     life functions, such as bathing, dressing,
Disabilities Act of 1990 (ADA).
                                                                                                                and eating. If you must have this person
                                                       2. Accessible, Lift-Equipped, and                        with you, please check this box:
The term comparable means that C-TRAN’s
paratransit service (C-VAN) is available on               Kneeling Bus Service
                                                         For people who cannot use steps, all                          Yes. I must have a personal care
the same days, during the same times, and in
                                                         C-TRAN buses are lift-equipped or are able                    attendant.
the same areas as noncommuter, regular bus
service.                                                 to kneel to help you get on and off the bus
                                                         easily. You can use the lift while standing or    B. Door-to-Door Service
Your disability or your age does not automati-           when using a mobility aid. The bus’ kneel-             C-VAN paratransit service is from the
cally qualify you for C-VAN service. Eligibility         ing feature allows easy access for people who          curb of your origin to the curb of your
for C-VAN is based on your functional ability            have a difficult time climbing stairs. The lift        destination. If your disability requires it,
to use a regular public transit bus. Therefore,          and kneeling features may be used at most              C-VAN may provide driver assistance to
as part of the C-VAN eligibility process, some           C-TRAN bus stops.                                      and from your door.* If you need this as-
applicants may be required to participate in an                                                                 sistance, please check this box:
in-person Functional Evaluation of their cur-            Do you have a disability that requires the
rent skills as they relate to riding a regular lift-     bus to kneel or employ the use of a lift to get               Yes. Please send me the form that
equipped and kneeling bus.                               on or off a regular bus?                                      allows door-to-door service.

ADA does not require a transit agency “. . . to              Yes.
meet all the transportation needs of individuals             No. This does not apply to me.                C. Hand-to-Hand Service
                                                                                                                If due to a disability a rider can never be
with disabilities.” ADA ensures that people
                                                                                                                left alone and needs delivery into the care
with disabilities receive the same public trans-       3. Getting To and From the Bus                           of another person, please check this box:
portation service opportunities everyone else            Do you have a disability that prevents you
receives.                                                from traveling to or from a bus stop?                         Yes. Please send me the form that
                                                                                                                       allows hand-to-hand service.
Completing this application is the first step in             Yes.
determining the right public transportation                  No. This does not apply to me.
service for you.                                                                                           *C-VAN drivers will guide customers to and
                                                         If you checked Yes to one or more ques-           from the entryway of the origin and destina-
Please answer the following questions about              tions, you will be sent additional questions      tion locations. They cannot support or carry
your use of the regular bus service.                     regarding your disability and use of public       mobility devices and are unable to enter a
                                                         transit.                                          home or facility.
                                                                                                           G:\Shared\Passenger Services\Forms\C-VAN Pre-application (format-
                                                                                                           ted for Web page) 8/19/08 cb
                             Applicant Questionnaire for Paratransit Service
Full Name:___________________________________ Date of Birth: ___________________________


Phone Number:____________________________

Paratransit eligibility may be granted to an individual with disabilities for any trip s/he would be unable
to make on the fixed route transit system.

C-TRAN requires the following information to determine your eligibility to start the application
process. The application process …

Independent Travel

1.          Do you have a cognitive or physical disability that, some or all of the time, prevents you from
            getting on, riding or getting off the bus by yourself, without the help of another person?

                                       o If yes, explain how and why:


2.          How does your disability prevent you from using Fixed Route buses?

3.          How many blocks are there from your residence to the nearest public bus stop?
              1-2      3-4       5-7      7-10      Greater than 1 mile       do not know.

4.          Do you live on a hill, graveled road, or other hard to navigate road or surface?
               Hill      Gravel road        other:______________________________________________

5.          Do your primary destinations have:
               Sidewalks       Sidewalks with curb cuts       Wheelchair ramps
               Other assessable amenities       More than 2 blocks from the road
               Controlled intersections such as pedestrian lights or crosswalks

G:\SHARED\Passenger Services\Forms-Blank Originals\Applicant Questionnaire for Paratransit Service.doc   June 20, 2008 cb
6.          How many blocks can you walk/wheel independently?
              0      1-2       3-4      5-7      7-10    Greater than 1 mile                                          do not know.

7.          Does your neighborhood have:
              Sidewalks       Sidewalks with curb cuts?

8.          Have you ever ridden a C-TRAN bus for any reason?
                              o Which routes_______________________________________
                              o How often_________________________________________
                              o When was your last trip_______________________________

                        If you answered yes, what types of trips were you making?
                                Grocery store    Shopping center       Doctor appointments Recreational

9.          What are the primary locations you will need transportation to?

            Please provide specific address.
            1. _____________________________________________________________________
            2. _____________________________________________________________________
            3. _____________________________________________________________________

10.         Do you know how to use a lift to board and deboard a bus?

11.         Have you ever successfully completed a travel training course?

12.         Do you use any mobility devices?
               Walker       Cane         Manual Wheelchair Power Wheelchair/Scooter

13.         Any other information regarding your disability you want to provide?

Applicants signature:__________________________________                                                  Date: _______________________

G:\SHARED\Passenger Services\Forms-Blank Originals\Applicant Questionnaire for Paratransit Service.doc                        June 20, 2008 cb

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