2. I. General Information
4. Date of birth*
   Date of birth
6. First and Last Name*
8. Address/Include Apartment Number if applicable*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Email Address
17. Mailing Address (if different)
19. City
20. State
21. Zip Code
23. II. Disability and Mobility Equipment Information
    Please describe the disability or health condition that prevents you from using fixed route buses. Be sure to list all disabilities or health conditions that apply.
25. Brief Description*
27. If this is a temporary disability or health condition, how long do you expect it to prevent you from using fixed route transit?
29. Do you use and mobility aids or equipment?

    Check all that apply

    1. Cane
    2. Crutches
    3. Walker
    4. Leg Brace

    1. Portable Oxygen
    2. Powered Wheelchair
    3. Powered Scooter
    4. Manual Scooter

    1. Long White Cane
    2. Service Animal
    3. I do not use any mobility aids
31. Do you ever require the assistance of a personal care assistant? *
    -- Select One --AlwaysSometimesNever
33. III. Ability to Utilize Fixed Route Transit Services
    Carefully read the following statements, and check all that describe your abilities to use fixed route transit
35. Select ALL that apply

    1. I can get to and from bust stops if the distance is not too great.
    2. I can ride the bus when I am feeling well. However, there are times when my disability or health condition worsens, and I am unable to ride the regular bus service.
    3. I have a disability or health condition that prevents me from riding the bus if the weather is too hot or cold.
    4. My disability or health condition makes it impossible for me to travel when there is snow or ice on the ground.
    5. I am unable to climb stairs to get on/off fixed route buses.
    6. I can get to and from bus stops only if there are curb-cuts and leveled sidewalks.
    7. I have difficulty understanding or remembering all the things I would have to do to use the bus.
    8. I can use fixed route buses without assistance.
    9. I am not sure if I can use fixed route buses.
    10. I am not able to use fixed route buses for other reasons
37. Explain why you are unable to use fixed route buses
39. IV. Please provide additional information about your functional abilities without assistance from another individual
41. Are you able to ask for and understand written instructions?*
    -- Select One --YesNoUnsure
42. Are you able to ask for and understand verbal instructions?*
    -- Select One --YesNoUnsure
44. Are you able to cross the street alone?*
    -- Select One --YesNoUnsure
45. Are you able to stand for 10 minutes if there is no place to sit?*
    -- Select One --YesNoUnsure
47. Are you able to step on and off a sidewalk from the curb?*
    -- Select One --YesNoUnsure
48. Are you able to walk up and down three steps with a handrail?*
    -- Select One --YesNoUnsure
50. Are you able to find your own way to the bus stop if someone shows you the way once?*
    -- Select One --YesNoUnsure
51. What is the farthest you can walk outdoors using your mobility aid without the assistance of another person?*
    -- Select One --Less than one block1 block2 blocks6 blocks (3/4 of a mile)More than 6 blocksI cannot travel alone outdoors
53. Are you able to transfer from one fixed route bus to another?*
    -- Select One --YesNoUnsure
54. Are you able to stand on a moving bus holding on to a handrail?*
    -- Select One --YesNoUnsure
56. V. Please provide information regarding your travel needs
    List places you frequent, and how you typically travel to these locations.
58. 1. Where do you go?*
59. 2. Where do you go?
61. How many times per week do you travel to this location?*
62. How many times per week do you travel to this location?
64. How do you currently get to this location?*
65. How do you currently get to this location?
67. 3. Where do you go?
68. Do you currently use fixed route buses?*
    -- Select One --YesNo
70. How many times per week do you travel to this location?
71. If yes, which routes?
73. How do you normally get to this location?
75. If you have stopped using fixed route transit please provide an explanation as to why.
77. Please print this document then sign and date below.
    I understand the purpose of this application is to determine if I am eligible to use ADA Paratransit Services. I certify the information provided in this application is true and correct. I further understand that falsification could result in loss of ADA Paratransit Services, as well as a penalty under the law. I agree to notify Port Arthur Transit if I no longer need ADA Paratransit Services.
79. Signature of Applicant
80. Date
82. If someone assisted in completing this application, please provide the following information:
84. Relationship to Applicant
86. Name
88. Address
90. City
91. State
92. Zip Code
94. Agency
95. Phone Number
97. It may become necessary to contact a professional who is familiar with your functional abilities and limitations. Please list a professional we can contact for additional information.
    Examples of qualified individuals include your physician, registered nurse, physical/occupational therapist, orientation and mobility instructor, psychologist, independent living specialist, social worker, case manager or rehabilitation specialist.
99. Name of Qualified Professional
101. Type of Professional
102. Phone Number
104. Address
106. City
107. State
108. Zip Code
110. Name of Qualified Professional
112. Type of Professional
113. Phone Number
115. Address
117. City
118. State
119. Zip Code
121. Authorization for Release of Information
     I authorize the listed professional(s) to release to Port Arthur Transit information regarding my disability or health condition, and its impact on my ability to travel on the fixed route bus system. I understand that I may revoke this authorization at any time. Unless earlier revoked, this form will permit the professional(s) listed to release the information described for up to 90 days from the date below. All medical information provided regarding your disability will be kept strictly confidential.
123. Date*
     Date
124. Signature of Applicant
126. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
Leave This Blank:


128. 1. Receive an email copy of this form.
129. Email address

     This field is not part of the form submission.

130. Submit Submit and Print

* indicates a required field