Application for Paratransit Services ADA ... - Lake County

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APPLICANT RELEASEI understand that the purpose of this evaluation application is to determine myeligibility for Lake County Connection paratransit service.I understand that the information about my disability contained in this applicationwill be kept confidential and the information may be verified with my health careprofessional.I hereby authorize my medical representative to release the pertinent medicalinformation regarding my condition to Lake County Connection if requested.I understand that providing false or misleading information could result in myeligibility status being revoked.I agree to notify Lake County Connection within 10 days, if there is a change incircumstances or I no longer need to use paratransit services.___________________________Applicant’s Signature_________________________DateIf applicant is unable to sign this form, he/she may have someone sign onhis/her behalf. I am signing on behalf of _____________________________._______________________ ______________________ __________Signature Relationship to Applicant DatePlease check which condition(s) prevents you/the applicant from accessing theregular Lake Express fixed route bus system._______________None, I’d rather use the door-to-door service.(Please complete Section A only.)The bus stop is too far or the bus does not run where I need to go.(Please complete Section B only.)My disability prevents me from using the regular bus system.(Please complete Section C and Section D only.)ADA ApplicationRevised 6/23/10
SECTION A1. How do you currently travel to your destinations?LakeXpress ____ Lake County Connection ____Taxi ____Drive myself ____ Other ____2. Do you have friends or relatives who can take you?Yes ____ No ____3. What is your annual household income? ___________________________4. How many people (including yourself) are in your household? __________5. Have you in the past 2 years, qualified for public assistance?Yes ____ No ____6. Do you have weekly scheduled medical appointments (such as dialysis,etc)?Yes ____ No ____If yes, please list: ______________________________________________7. How many medical appointments do you have a month?1-2 ____ 3-4 ____ 5-6 ____ More than 7 ____8. Do you or anyone in your household own or have a car?Yes ____ No ____ (Information may be verified by DMV)9. Would you like to ride LakeXpress if you were provided with a bus pass?Yes ____ No ____10. Do you have any of the following? (Please check all that apply.)____ I am on portable oxygen____ I have a sight impairment____ I am totally blind____ I need assistance walking____ I use a cane____ I need an escort____ I must travel by wheelchair____ I have a personal care attendant____ I have a medical impairment____ I am legally blind____ I have a hearing impairment____ I use a walker____ I have a service animal____ I use crutches____ I must travel by stretcher_______________________________Applicant’s NameADA ApplicationRevised 6/23/10
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Application for Paratransit Services ADA ... - Lake County

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