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HomeSENIOR SUPPORTIVE SERVICESTransportationIndian River Transit Community Coach Paratransit Eligibility Application

Indian River Transit Community Coach Paratransit Eligibility Application

INSTRUCTIONS FOR COMPLETING THIS APPLICATION: Please complete all parts of this application in order to be considered for multiple programs.

Step 1 of 8

12%
  • MM slash DD slash YYYY
  • Contact Name
  • Contact Name
    *NOTE: The Community Coach is able to accommodate wheelchairs up to 30 inches wide and 48 inches long. The maximum weight limit is 800 lbs (200 lbs more than the average of 600 lbs.)
    (A PCA is a person who must travel with you to assist with your daily life functions.)
  • I understand that the information in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility for the provision of transportation services. The information will not be provided to any other person or agency. I certify that, to the best of my knowledge, the information in this evaluation form is true and correct. I understand that any person who knowingly makes false or misleading statements in an application may be denied paratransit eligibility.
  • MM slash DD slash YYYY
  • If someone, other than the client assisted with the completion of this application please provide their contact information below:
  • MM slash DD slash YYYY
    IN THE EVENT OF AN EVACUATION: To register with the Indian River County Department of Emergency Services: 4225 43rd Avenue Vero Beach, Florida 32967 Phone: (772) 226-6900
  • Total Monthly Income (*Question is required, but not used in determining eligibility.)
    (Caring for oneself, performing manual tasks, seeing, eating, hearing, etc.)
    To qualify for the Community Coach, a person must be UNABLE to use the GoLine fixed-route bus system of Indian River County due to a physical or mental impairment.
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Senior Resource Association 694 14th Street Vero Beach, FL 32960 Phone: 772.569.0760 Fax: 772.778.7272 Office hours: 8:30am to 5:00pm info@sramail.org
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