Indian River Transit Community Coach Paratransit Eligibility Application

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth:*
MM slash DD slash YYYY
Email*
Do you have Medicaid?*
- Yes
- No
If yes, Medicaid number:
Gender:*
- Male
- Female
Contact Number:*
Secondary Contact Number:
In the event of an emergency, please notify:

Contact Name
Relationship of Emergency Contact:
Emergency Contact Phone Number:
In the event of an emergency, please notify:

Contact Name
Relationship of Emergency Contact:
Emergency Contact Phone Number:

Do you need information provided to you in an alternative format?*
- Yes
- No
If yes, please indicate which alternative format is preferred:*
- Large print
- Audio CD/Tape
- Braille
- Other
Other, please specify:
Electronic Applicant Signature:*
First Last
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.
Date*
MM slash DD slash YYYY

American's With Disability Act Program: Please indicate below the reasons you are seeking Door to Door eligibility. Check all applicable:*
- because of my disability, I can never use the GoLine bus service.
- I can use the GoLine occasionally, but the buses need to be equipped with wheelchair lifts.
- I can use the GoLine to travel to a few places, but I have trouble getting to and from the bus stops in other place.
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.
What type of disability prevents you from using the GoLine Buses? (check all that apply).*
Other, please specify:
Please describe your disability in more detail:
Is the disability described above temporary or permanent?*
- Temporary
- Permanent
- I don't know
If temporary, how long do you expect it to last?
Have you ever used the GoLine fixed-route bus service?*
- Yes
- No
If yes, what bus routes do you use?

When are you UNABLE to use the GoLine fixed-route bus system? Please indicate all that apply.*
Would any of the following help you to use the fixed-route transit system? Check all that apply*

Are you able to ask for and follow written/verbal instructions on how to use the GoLine fixed-route bus system?*
- No
- Sometimes
- Yes
If you ansered No or Sometimes, please review the statements below. Select all that apply.*
other, please specify:
Are you able to do the following without assistance: (Check all that apply)*

How far can you walk or travel with the assistance of a mobility aid?*
- I cannot travel outside my residence
- I am able to get to the curb in front of my residence
- Up to 3 blocks, walking or with the assistance of a wheel chair
- Up to 6 blocks, walking or with the assistance of a wheel chair
- Up to 9 blocks, walking or with the assistance of a wheel chair
Can you wait up to 30 minutes for the GoLine bus at a bus stop?*
- Yes
- Yes, only if there is a bench or a shelter at the stop
- Yes, but I don;t like to wait that long
- No
If no, please explain:

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