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ADA Paratransit Service Application

  2. Are there sidewalks at your residence
  3. Can you get to this bus stop by yourself?
  4. Can you board the bus by yourself?
  5. If vision-impaired, are you able to travel a distance of 200 feet without assistance?
  6. Are you able to travel a distance of 3 blocks (1/4) without assistance over different types of terrain?
  7. Are you able to climb three 12-inch steps without assistance?
  8. Are you able to cross a 2-way stop?
  9. Are you able to cross a 4-way stop?
  10. Are you able to cross a traffic light-controlled intersection in the following areas?
    Select all that apply
  11. If you have a cognitive disabiliity, are you able to give name, address, and telephone numbers upon request?
  12. Are you able to recognize your destination or landmark?
  13. Can you deal with unexpected situation or unexpected changes in rountine?
  14. Can you ask for, understand, and follow directions?
  15. Can you safely and effectively travel trough crowded and/or complex facilities?
  16. Do you use Orange County Public Transportation fixed-route buses now?
    Select all that apply
  17. Have you ever received any training to use the fixed-route bus service?
  18. If not, would you like to participate in training?
  19. Do you use any of the following assistive devices?
    Select all that apply
  20. Applicant Agreement
    I agree that, if I am certified for Orange County Public Transportation ADA Paratransit, I will pay the exact fare, if required, for each trip. I agree to notify the office of any changes in my status that may affect my eligibility to use the service. I also understand that failure to adhere to the policies and procedures will be grounds for revoking my application and the right to participate in the program. I understand and agree to hold Orange County and Orange County Public Transportation harmless against all claims or liability for damages to any person, property, or personal injury occurring as a result of my failure to equip or maintain the safety of the adaptive equipment or certified guide/service animal that I require for mobility. I hereby authorize the release of verification information and any additional information to Orange County/Orange County Public Transportation for the purpose of evaluating my eligibility to participate in the Program. I certify that the information provided in this application is true and correct.
  21. Please sign
  22. If someone assisted you incompleting this application, please provide his/her information and signature below:
  23. Please sign
  24. This portion to be fill out by Health Care Professional Only
  25. Orange County Public Transportation Health Care Professional ADA Paratransit Verification of Eligibility
    As a requirement of the Americans with Disabilities Act of 1990 (ADA), Orange County Public Transportation is a federally subsidized public transportation service set aside for passengers who are prevented from using fixed -route service due to a mobility limitation. ADA paratransit service is not intended to include persons who find it inconvenient or even difficult to get to or from fixed-route bus stops. Disability alone is not an automatic qualifying determinant for ADA paratransit bus service. As a medical provider, you are uniquely familiar with the genera health and abilities of your patent. As such please provide answer to the following question as they relate to mobility limitations resulting from a functional or cognitive disability. All information for verification of eligibility must be filled in by a qualified health care professional.
  26. If you mark No or Sometimes on any of the following itesm, please explain.
  27. Is this condition:
  28. Please list the dates of duration.
  29. Does the applicant's disability require that he or she travel with an attenant
    Please check the option that applies
  30. If the person has a congnitive disability, is he or she able to give name, address, and telephone number upon request?
  31. Recongnize a destination or landmark
  32. If the person is speech impaired, is he or she able to communicate verbally?
  33. I verify that the information provide above for verifivation is true and correct to the best of my knowlegde.
  34. Please Sign
  35. Instructions for submission
    Once the completed form has been printed please mail in the form to our Administrative Office : 600 NC 86 Hillsborough, NC 27278 or fax the form to (919) 732-2137
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