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Port Arthur Transit ADA Paratransit Application for a minor/individual with a legal guardian

  1. I. General Information
  2. 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.
  3. Do you use and mobility aids or equipment?
    Check all that apply
  4. 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
  5. Select ALL that apply
  6. IV. Please provide additional information about your functional abilities without assistance from another individual
  7. V. Please provide information regarding your travel needs
    List places you frequent, and how you typically travel to these locations.
  8. Statement of Understanding
    I understand the purpose of this application is to determine if the applicant named on this form, of whom I am the parent/legal guardian, is eligible to use ADA Paratransit Services. I certify the information provided in this application is true and correct. I further understand that falsification of information could result in loss of ADA Paratransit Services, as well as a penalty under the law. I agree to notify Port Arthur Transit if the applicant named on this form is no longer in need of ADA Paratransit Services.
  9. If someone, other than the applicant, assisted in completing this application, please provide the following details:
  10. 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 professionals include your physician, registered nurse, physical/occupational therapist, orientation and mobility instructor, psychologist, independent living specialist, social worker, case manager or rehabilitation specialist.
  11. 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.
  13. Leave This Blank:

  14. This field is not part of the form submission.