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SENIOR SUPPORTIVE SERVICES
Transportation
Indian 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%
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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:
Please indicate if you use one or more of the following mobility aids and/or equipment listed below:
*
Cane
Crutches
Leg Braces
White Cane
Oxygen
Service Animal
Manual Wheelchair
Powered Wheelchair
Sighted (Person) Guide
Walker
Oxygen Tank or other portable medical equipment
I do not use mobility aids or equipment
Other
*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.)
Other (please specify)
Do you require the assistance of a Personal Care Attendant (PCA)?
*
Never
Sometimes
Always
(A PCA is a person who must travel with you to assist with your daily life functions.)
Can you be left unattended?
*
Yes
No
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
Name
First
Last
If someone, other than the client assisted with the completion of this application please provide their contact information below:
Date
MM slash DD slash YYYY
Address
Relationship to Applicant:
Street Address:
City
State / Province / Region
ZIP / Postal Code
In the event of mandatory evacuation order issued by Indian River County Emergency management due to a hurricane or flood, would you need transportation to a shelter?
*
Yes
No
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
To apply for the Transportation Disadvantaged (TD) Program, please complete the following:
*
Total Monthly Income (*Question is required, but not used in determining eligibility.)
Do you have a physical or mental impairment that substantially limits one of your major life activities?
*
No
Sometimes
Always
(Caring for oneself, performing manual tasks, seeing, eating, hearing, etc.)
Please specify the nature of the impairment
*
Mobility Impairment (stroke, Brain/ Spinal/ Nerve trauma)
Neurological Disability (MS, MD, Cerebral Palsy, Epilepsy, Alzheimer's, Parkinson's, Other)
Visual Disability (Macular Degeneration, visually impaired, legally blind)
Uncontrolled Fatigue (Chemo/ Radiation, Dialysis)
Cognitive or Sensory Impairment (Autism, Down Syndrome, Dementia, Developmental, Other)
Impairment Related (hearing Impairment, Cardiac Impairment, COPD/ Respiratory, Arthritis, Neuropathy)
Other
Other, Please Specify
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).
*
Mobility Impairment (stroke, Brain/Spinal/Nerve Trauma)
Neurological Disability (MS, MD, Cerebral Palsy, Epilepsy, Alzheimer's, Parkinson's, Other)
Visual Disability (Macular Degeneration, visually impaired, legally blind)
Uncontrolled Fatigue (Chemo/ Radiation, Dialysis)
Cognitive or Sensory Impairment (Autism, Down Syndrome, Dementia, Developmental, Hearing Impairment, Other)
Impairment Related (Cardiac, COPD, Respiratory, Arthritis, Neuropathy)
Other
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.
*
I can use GoLine bus services for some trips. Other times there are barriers that prevent me from using the bus.
I have difficulty understanding and remembering the instructions to use the bus. I am easily disoriented.
I can only get to and from the bus stops if: the distance to the bus stop is not too great and there are curbs and sidewalks along the route.
I can only wait at GoLine bus stops if there is a bus shelter/bench available. I cannot cross busy streets and/or intersections.
The severity of my disability changes from day to day. I can only ride the GoLine Fixed-route transit when I am feeling well.
I have difficulty (or unable to ) climbing stairs. I can only board a GoLine bus if it has a ramp or lift.
I have a health condition that prevents me from using the GoLine bus if the walk to the bus stop is too far or if the weather is too hot.
Would any of the following help you to use the fixed-route transit system? Check all that apply
*
Route and schedule information
Bus stops closer to your home
A communication aid
Bus stops closer to where I live and need to go
Travel training on how to utilize the bus service
None of these would be helpful
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.
*
I get confused and am afraid I might get lost.
Other people have difficulty understanding me.
Most Likely, I could ride the GoLine with proper instruction.
Other
other, please specify:
Are you able to do the following without assistance: (Check all that apply)
*
Walk up and down three steps when there are handrails provided
Use a telephone
Ask for and follow instructions (written or oral)
Cross the street if there are curb cuts present
Get on/off a GoLine bus when there is a wheelchair lift present
Easily hear the bus driver's voice, inside or outside the bus, when he/she announces the bus routes
Step on and off a sidewalk that does not have a curb cut
Cross streets and intersections
Navigate yourself to a bus stop if someone shows you the way once
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: