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2. 
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Date
    Date
15. Date of Birth
    Date of Birth
17. What diability prevents you from using Orange County Public Transportation Fixed-Route Bus Service? Please specify all that apply.
19. How does your disability prevent you from using Orange County Public Transportation Bus Service?
21. Please describe the area where you (e.g. rural, urban,suburban, flat, very steep hill, gradual hill, etc.)?
23. Are there sidewalks at your residence

    1. Yes
    2. No
25. What is the most difficult part of riding the bus for you?
27. What is the closest bus stop to your home? (Please give a location)
29. Can you get to this bus stop by yourself?

    1. Yes
    2. No
    3. Sometimes
30. Can you board the bus by yourself?

    1. Yes
    2. No
    3. Sometimes
32. If vision-impaired, are you able to travel a distance of 200 feet without assistance?

    1. Yes
    2. No
    3. Sometimes
33. Are you able to travel a distance of 3 blocks (1/4) without assistance over different types of terrain?

    1. Yes
    2. No
    3. Sometimes
35. Are you able to climb three 12-inch steps without assistance?

    1. Yes
    2. No
    3. Sometimes
36. Are you able to cross a 2-way stop?

    1. Yes
    2. No
    3. Sometimes
37. Are you able to cross a 4-way stop?

    1. Yes
    2. No
    3. Sometimes
39. Are you able to cross a traffic light-controlled intersection in the following areas?

    1. Residential
    2. Semi-Business
    3. Business

    Select all that apply
40. If you have a cognitive disabiliity, are you able to give name, address, and telephone numbers upon request?

    1. Yes
    2. No
    3. Sometimes
42. Are you able to recognize your destination or landmark?

    1. Yes
    2. No
    3. Sometimes
43. Can you deal with unexpected situation or unexpected changes in rountine?

    1. Yes
    2. No
    3. Sometimes
45. Can you ask for, understand, and follow directions?

    1. Yes
    2. No
    3. Sometimes
46. Can you safely and effectively travel trough crowded and/or complex facilities?

    1. Yes
    2. No
    3. Sometimes
48. Do you use Orange County Public Transportation fixed-route buses now?

    1. Yes
    2. No
    3. Sometimes

    Select all that apply
49. If No or Sometimes what limites or prevents you from usingthe buses? (e.g. no sidewalks)
51. Have you ever received any training to use the fixed-route bus service?

    1. Yes
    2. No
52. If not, would you like to participate in training?

    1. Yes
    2. No
54. If you do not ride Orange County Public Transportation fixed-route buses, how do you currently travel? (e.g. family, friends, volunteer drivers)
56. Do you use any of the following assistive devices?

    1. Manual Wheelchair - passenger can transfer to a seat
    2. Manual Wheelchair - passenger cannot transfer to a seat
    3. High Wheelchair
    4. Long Wheelchair
    5. Electric Wheelchair
    6. Power Scooter

    1. Walker (Foldable)
    2. Cane
    3. Crutches
    4. Service Animal
    5. Oxygen

    Select all that apply
58. If you use a mobility assistance device such as a wheelchair or power scooter, what is the total weight of the device inclusive of the passengerwhen the deice is in use?
60. 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.
62. Signature
    Please sign
63. Date
    Date
65. If someone assisted you incompleting this application, please provide his/her information and signature below:
67. Name
68. Email Address
70. Address
72. City
73. State
74. Zip Code
76. Phone Number
78. Signature
    Please sign
79. Date
    Date
81. This portion to be fill out by Health Care Professional Only
83. 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.
85. Person Completing Verification
87. Professional Title
89. Agency Affiliation
91. State of North Carolina Certification ID Number
93. Business Name & Phone Number
95. Business Address
97. City
98. State
99. Zip Code
101. If you mark No or Sometimes on any of the following itesm, please explain.
103. What is the medical diagnosis that auses the disability? ( e.g. epilepsy, intelletual & development disability)
105. Is this condition:

     1. Temporary
     2. Permanet
106. If Temporary, what is the expected duration?
     Please list the dates of duration.
108. Does the applicant's disability require that he or she travel with an attenant

     1. Yes
     2. No
     3. Sometimes

     Please check the option that applies
109. Explain:
111. Is there any other medical information we should know in the event of an emergency? (e.g. hepatitis, tuberculosis, cardiac)
113. If the person has a congnitive disability, is he or she able to give name, address, and telephone number upon request?

     1. Yes
     2. No
     3. Sometimes
115. Explain
117. Recongnize a destination or landmark

     1. Yes
     2. No
     3. Sometimes
118. Explain
120. If the person is speech impaired, is he or she able to communicate verbally?

     1. Yes
     2. No
     3. Sometimes
122. Explain
124. I verify that the information provide above for verifivation is true and correct to the best of my knowlegde.
126. Signature of Qualified Professional
     Please Sign
128. 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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129. Print Only

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