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CITY OF MOORPARK RE : ADA eligibility applications (City of Moorpark)

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CITY OF MOORPARK
CITY ENGINEER/PUBLIC WORKS DEPARTMENT | 799 Moorpark Avenue, Moorpark, California 93021
Main City Phone Number (805) 517-6200 | Fax (805) 532-2555 | www.moorparkca.gov
RE
: ADA eligibility applications
Dear Resident of Moorpark:
Thank you for your interest in the City of Moorpark’s ADA Paratransit service. This transit service is for
persons with a disability that prevents or impairs them from using the Moorpark City Transit fixed-route
buses. Please complete the enclosed application and send it to the address provided on
the application. You can also complete the application online by
visiting:
Enclosed is information on the City ADA Paratransit and Senior Dial-A-Ride services. A Senior Dial-A-
Ride application is also included if you are interested in the program. If I can be of any further
assistance, please do not hesitate to call me at 805-517-6257, and I will be happy to assist you.
S
incerely,
S
haun Kroes
Program Manager
Enclosures
- About ADA
- ADA Paratransit
- ADA Application
- Senior DAR Application
- Moorpark Senior Dial-A-Ride
- CONNECT Brochure
https://www.goventura.org/getting-around/ada-certification/
If you have any questions about the application, please call 1-888-667-7001.
About ADA
The Americans with Disabilities Act (ADA) is a federal law that was passed in 1990.
This law prohibits discrimination on the basis of disability in employment, public
services, transportation, public accommodations and telecommunications. The purpose
of the law is to provide equal public transportation for anyone, who because of their
disability or condition is unable to independently access or use regular transit service.
You may be eligible under the established ADA criteria if you are unable to use the
public bus service for one or more of the following reasons::
You are unable to board, ride or disembark from an accessible transit vehicle.
Your disability or condition prevents you from traveling to or from a bus stop.
To become eligible to use any ADA transportation service in Ventura County, complete
an application for ADA eligibility certification. The application requires you (or someone
completing the form on your behalf) to explain why you are unable to use the regular
public bus service.
The attached application can be m
ailed or faxed to VCTC’s ADA Certification
Coordinator (contact information is provided on the back of the application). An online
application process is also available through VCTC. The website is:
www.goventura.org/getting-around/ada-certification/
For additional information on the ADA application process, please call (888) 667-7001.
ADA Paratransit
Moorpark ADA Paratransit service works just like the Senior Dial-A-Ride with some
additional services. It is available to any person qualified with a disability regardless of age.
The ADA Paratransit provides origin to destination transportation within the City of Moorpark
(see below for InterCity travel information).
To qualify, a person must become “ADA certified.” A four-page application must be
completed in order to enroll in the program. Applications are available at the Active Adult
Center, by calling Shaun Kroes at City Hall (805-517-6257), calling the Ventura County
Transportation Commission at 1-888-667-7001, or visiting www.goventura.org. A
representative of the Ventura County Transportation Commission will contact the applicant
for an assessment interview. Once approved, the applicant is deemed “ADA certified” in
compliance with the Americans with Disabilities Act of 1990. Wheelchair accessible rides are
available. If you are traveling with a wheelchair, please call at least a day in advance to book
your ride.
How to Order a Ride: Once enrolled in the program, call Thousand Oaks for a ride at least
2 hours in advance of needing the ride, (805) 375-5467. When calling, tell the operator, “I’m
a Moorpark Dial-A-Rider.” Thousand Oaks has several contracts with local agencies, telling
them that you are a “Moorpark Dial-A-Rider” will let them know which program you belong
to.
If you will be waiting for your ride inside a building’s lobby, let the operator know.
If you have an appointment you need to get to by a set time, let the operator know.
Fare: $2.00 each way. Exact change. Cash only.
The City of Moorpark is also a member of the East County Transit Alliance (ECTA) which
operates CONNECT InterCity Dial-A-Ride. Travel is provided to Agoura Hills, Camarillo,
Oak Park, Simi Valley, Thousand Oaks, and Westlake Village. Please see enclosed
CONNECT City to City brochure for additional information.
Fare: $5.00 each way. See brochure for payment methods.
Hours of Operation: 6:00 a.m. - 6:00 p.m. Monday through Friday, and 8:00 a.m. to 6:00
p.m. on Saturdays; excluding City holidays.
1
Applicant Full Name
Residence Address Apt/Unit #
City State Zip Code
Mailing Address (if different) Apt/Unit#
City State Zip Code
Home Telephone
Alternate Phone
Date of Birth Language Pref. Gender
Email Medi-Cal #
Emergency Contact Info
Full Name Relationship
Address Phone Alt. Phone
Application for ADA Eligibility Certification Program
☐ New Applicant ☐ Recertification
If recertification, please include current ADA ID#
2
The following terms may be used during the application process and are
defined as follows
Personal Care Attendant (PCA) – The Americans with Disabilities Act (ADA) defines a
personal care attendant (PCA) as someone designated or employed specifically to help
a person with his or her personal needs. If you have a family member, friend or neighbor
who helps you or if someone has been hired to help you with certain activities, they
would qualify as a personal care attendant (PCA).
Public Bus – A bus that runs along a fixed route with a specific schedule of stops.
Paratransit (Dial-a-Ride) – A transportation service which operates in response to calls
from passengers to the local transit operator. Vehicles pick-up passengers and transport
them to their destinations. The vehicles do not operate over a fixed route or on a specific
schedule.
1. Do you have a disability that prevents you from using a public bus?
☐ Yes ☐ No
If yes, please explain.
2. Please review the list below and indicate which (if any) conditions apply to you.
☐ Difficulty breathing ☐ Mental health
☐ Nerve condition ☐ Intellectual
☐ Seizure disorder ☐ Developmental
☐ Heart condition ☐ Mobility
If this application has been completed by someone other than the
applicant, please complete the following
First/Last Name
Agency Phone Number
*This person is not able to access information about this application unless also listed as a
legal conservator
Please note: If and when you qualify for ADA certification, it is not a guarantee that origin
to destination services will be available in your service area. Please check with your
local paratransit operator to ensure which areas are covered. At the discretion of the
paratransit company, limitations may also apply where the paratransit vehicle is unable to
safely navigate to/from a specific location.
3
Vision Hearing
☐ Low
☐ Blind
☐ Require guidance to get on the bus
☐ Other (please explain)
☐ Hard of hearing
☐ Deaf
☐ Other (please explain)
3. When did the above condition(s) begin?
☐ 0-1 year ago ☐ 1-5 years ago ☐ Longer than 5 years ago
4. Is your disability considered…
☐ Temporary ☐ Stable ☐ Progressive
5. Does your disability change after medical treatments or medications?
☐ Yes ☐ No ☐ Sometimes
If yes or sometimes, please explain.
6. Do you use any of the following Mobility Devices/Assistive Technology?
☐ Yes ☐ No
If yes, please check all that apply
☐ Support cane ☐ Scooter
☐ White cane ☐ Crutches
☐ Collapsible walker (with or w/o seat) ☐ Leg braces
☐ Walker with seat ☐ Charcot boot
☐ Manual wheelchair ☐ Portable oxygen device
☐ Reclining wheelchair ☐ Hearing aid (s)
☐ Power chair
7. Do you use a communication device?
☐ Yes ☐ No
If yes, what type of device do you use?
8. Do you have a service animal?
☐ Yes ☐ No
If yes, what type of animal do you have?
How does your service animal help you?
4
9. If you use a wheelchair or scooter, do you know about how much you and your
wheelchair/scooter weigh together?
☐ Yes ☐ No
If yes, please indicate below
☐ Under 300 lbs ☐ 300-600lbs ☐ Over 600 lbs
10. Do you know the approximate dimensions of your wheelchair?
☐ Yes ☐ No
If yes, please provide the dimensions (in inches).
Width Depth Height
11. Do you need the help of another person to leave your residence
(down a driveway, over a threshold, down a flight of stairs)?
☐ Yes ☐ No ☐ Sometimes
If sometimes, please explain.
12. Do you need the help of another person to travel out in the community?
☐ Yes ☐ No ☐ Sometimes
If sometimes, please explain.
13. Please tell us which of the following you are able to do (please check all that apply).
☐ Go up and down 3 or 4 stairs
☐ Go up and down a hill
☐ Go up and down a curb
☐ Go across pavement that has raised bumps on it
☐ Cross a two lane street before the signal turns red
☐ Travel by yourself in the evening or early morning with limited light
☐ Travel to the nearest public bus stop in weather that is very hot
☐ Travel to the nearest public bus stop in weather that is very cold
☐ Stand at a public bus stop if there is no seating
☐ Wait at a public bus stop if there is no shade
☐ Go up or down a ramp
☐ Get on and off a public bus if it has a lift Continued on next page
Please note: If you need help in completing Questions 9 and 10 below, please call us at
888.667.7001 and we will help you.
5
☐ Grasp handles or railings when getting on and off of a public bus
☐ Keep your balance while seated on a moving vehicle
☐ Recognize street signs
☐ Read letters and numbers on street signs and buses
☐ Follow written instructions
☐ Follow oral instructions
☐ Read lips (if deaf)
☐ Handle coins or paper money
☐ Count change
☐ Tell time
The following questions are to help us understand if you are able to use the public bus
system safely and independently. Whether or not you have used public transit recently or
in the past will not prevent you from being eligible to apply for ADA paratransit services.
14. Do you know who your local transit company is?
☐ Yes ☐ No
If yes, please list.
15. Have you ever used the public bus, trolley, or trains?
☐ Yes ☐ No
If yes, how long ago and how frequently did (do) you use these types of transportation?
16. How close is the nearest public bus stop to your home?
☐ Less than 2 blocks ☐ More than 4 blocks
☐ 2-4 blocks ☐ I don’t know
17. Are you able to travel to the nearest public bus stop independently?
☐ Yes ☐ No ☐ Sometimes
If no or sometimes, please explain.
6
18. Please tell us about any barriers that prevent you from using the public bus or train.
Please check all that apply.
☐ I can’t walk/travel that far
☐ There are no sidewalks
☐ The sidewalk is broken
☐ There are hills
☐ There are no crosswalks
☐ There are no sidewalk ramps
☐ There are streets I cannot cross quickly enough
☐ There are no signals at the streets I need to cross
☐ There is no seating/bench at the closest public bus stop
☐ I don’t know, I have never tried to walk/travel to the public bus stop
19. Are there any other reasons that are keeping you from reaching/using the public
bus stop?
20. From where the public bus stop lets you off are you able to reach where you
are going?
☐ Yes ☐ No ☐ Sometimes
If no or sometimes, what keeps you from being able to do this on your own?
21. How long are you able to wait at a public bus stop? Please check all that apply:
☐ More than 10 minutes ☐ 10 minutes if I can sit down
☐ 10 minutes if there is shade ☐ 5 minutes if I can sit down
☐ 5 minutes if there is shade ☐ Not at all
22. Are you able to complete transfers on the public bus (using more than one bus to
get to where you are going)?
☐ Yes ☐ No
If yes, how many transfers can you complete?
7
23. Please list below two of your most frequent destinations, how often you go and how
you currently get there.
24. Have you ever had any type of training to use the public bus, trolley, or train?
☐ Yes ☐ No ☐ Sometimes
If yes, how long ago was this training? What did you learn?
25. Would you be interested in additional training?
☐ Yes ☐ No ☐ Maybe later
26. Would you be interested in learning about other cost effective transportation options
that may be available in your community?
☐ Yes ☐ No
27. Please add any additional comments or information that you believe will help us
determine your eligibility for ADA services.
A. Location Name
Location Address
How Often?
☐ Daily ☐ Weekly ☐ Monthly ☐ Other
How do you currently get there?
☐ Drive ☐ Bus ☐ Train ☐ Dial-A-Ride ☐ Other (please specify)
B. Location Name
Location Address
How Often?
☐ Daily ☐ Weekly ☐ Monthly ☐ Other
How do you currently get there?
☐ Drive ☐ Bus ☐ Train ☐ Dial-A-Ride ☐ Other (please specify)
8
Authorization for Release of Health Information
I hereby certify that the information given here is complete and correct to the best of
my knowledge. I understand that I may be required to attend an in-person interview
and assessment before a determination of eligibility is made. I understand that if I am
not found to be eligible for ADA paratransit service that I may appeal the determination
within 60 days after receipt of written determination, and that I will be advised of the
procedures of such an appeal. In addition, I hereby authorize the person listed below to
release to the Ventura County Transportation Commission information about my disability
in order to verify my eligibility for ADA paratransit service. The information released will
be used to assist in determining eligibility for ADA paratransit services, and given to
agencies to provide appropriate transportation access and accommodation.
First and Last Name of Health Professional Verifying Your Health Information
Occupation/Specialty
Organization Name
Health Professional Phone Number (Required)
Health Professional Fax Number (Required)
Applicant’s Signature Date
Conservator/Guardian* Signature Date
Printed name of Conservator/Guardian*
*Note: A conservator/guardian is a person who is legally authorized to sign medical
documents for the applicant and to receive information about the ADA application. An
applicant does not have to designate a conservator/guardian. If no conservator/guardian
is noted, no one besides the applicant will be able to obtain information regarding the
application.
Please return the completed application via mail, email, fax or walk-in to:
Ventura County Transportation Commission
C/O Mobility Management Partners (MMP)
ATTN: ADA Certification Coordinator
330 Wood Road, Suite A, Camarillo, CA 93010
Email: info@mobilitymp.org Fax: 1-888-667-7002
Once your application has been received by MMP, you may be eligible for paratransit
services in your city until your determination is completed. For further information, please
contact your local paratransit operator directly.
Senior Dial-A-Ride
Application
Please complete this form, or have someone complete it on your behalf. Please print or type.
Applicant must be 65 or older to qualify for the ECTA InterCity DAR program.
Your Name:
Home Address (No PO Boxes):
City:
State:
Phone:
Birth Date:
Do you use any of the following?
□
Wheelchair
□
Cane
□
Walker
□
Scooter
Emergency
contact person:
Relationship:
Address:
Emergency
Phone:
City:
State:
I certify under penalty of perjury that the information contained in this application is true & correct.
Signature: Date:
Please return completed form to:
If a Moorpark Resident: If Simi Valley Resident:
If Thousand Oaks or
Unincorporated Resident
within the ECTA Service Area:
City of Moorpark – Transit Div.
799 Moorpark Avenue
Moorpark, CA 93021
805-375-5467
805-532-2555 (fax)
www.moorparkca.gov/transit
mct@moorparkca.gov
Simi Valley Transit
2929 Tapo Canyon Road
Simi Valley, CA 93063
805-375-5467
805-583-6490 (fax)
www.simivalley.org/transit
simitransit@simivalley.org
Thousand Oaks Transit
265 S. Rancho Road
Thousand Oaks, CA 91361
805-375-5467
805-375-5472 (fax)
www.totransit.org
totransit@toaks.org
Out of area residents and visitors qualify for local and intercity senior dial-a-ride services. Contact
Thousand Oaks Transit for additional information on applying for temporary service eligibility.
Moorpark Senior Dial-A-Ride
The City of Moorpark Senior Dial-A-Ride program provides origin to destination
transportation throughout the City of Moorpark to Moorpark residents age 65 and older. The
City contracts with the City of Thousand Oaks (Thousand Oaks) for Senior DAR services.
Wheelchair accessible vehicles are available, but if you are traveling with a wheelchair, call
at least a day in advance to book your ride; be sure to tell the operator whether you have a
wheelchair or a scooter. Your trip may be combined with other riders. This helps keep costs
down and reduces wait times for everyone.
How to Order a Ride: Once enrolled in the program, call Thousand Oaks for a ride at least
2 hours in advance of needing the ride, (805) 375-5467. When calling, tell the operator, “I’m
a Moorpark Dial-A-Rider.” Thousand Oaks has several contracts with local agencies, telling
them that you are a “Moorpark Dial-A-Rider” will let them know which program you belong
to.
If you will be waiting for your ride inside a building’s lobby, let the operator know.
If you have an appointment you need to get to by a set time, let the operator know.
Fare: $2.00 each way. Exact change. Cash only.
The City of Moorpark is also a member of the East County Transit Alliance (ECTA) which
operates CONNECT InterCity Dial-A-Ride. Travel is provided to Agoura Hills, Camarillo,
Oak Park, Simi Valley, Thousand Oaks, and Westlake Village. Please see enclosed
CONNECT City to City brochure for additional information.
Fare: $5.00 each way. See brochure for payment methods.
Hours of Operation: 6:00 a.m. - 6:00 p.m. Monday through Friday, and 8:00 a.m. to 6:00
p.m. on Saturdays; excluding City holidays.
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CITY OF MOORPARK RE : ADA eligibility applications (City of Moorpark)

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Completed 4 August 2020

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