Fillable HANDI-VAN ENROLLMENT APPLICATION (Town of Smithtown)

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HANDI-VAN ENROLLMENT APPLICATION (Town of Smithtown)

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  • 33 check-boxes
  • 77 other fields

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TOWN OF SMITHTOWN
OFFICE FOR PEOPLE WITH DISABILITIES
420 MIDDLE COUNTRY ROAD
SMITHTOWN, NEW YORK 11787
PHONE: 360-7642 FAX: 360-7689
handicappedservices@tosgov.com www.smithtownny.gov
HANDI-VAN ENROLLMENT APPLICATION
PART 1 (To be completed by the Applicant) Page 1 of 2
Applicant’s Last Name First Name M.I.
Address of Applicant’s Residence
Phone Number (Day)
Phone Number (Cell )
Date of Birth
Who should be contacted in case of Emergency?
Phone Number (Day)
Phone Number (Cell)
Relationship to Applicant
Mailing Address of Emergency Contact:
Only complete this section to designate another person (“Third Party”)
to be contacted regarding this program and the applicant’s use of it.
Name of ‘Third Party’ Contact
Phone Number (Day)
Phone Number (Cell)
Relationship to Applicant
Mailing Address of Third Party Contact
Should this designated individual
be contacted INSTEAD of the
applicant?
If “Yes”, briefly explain why:
FOR OFFICE FOR PEOPLE WITH DISABILITIES USE ONLY:
Enrollment Date: _________________ Re-Certification Date: ____________________
PART 1 (continued) Page 2 of 2
MOBILITY AIDS ----- Check the mobility aids you travel with:
Cane Wheelchair* (Manual) Service Animal
Walker Wheelchair* (Electric) Other:
Braces Powered Scooter*
*If you use a wheelchair
or a scooter, can you
transfer to a seat?
Do you require the
use of a bus lift?
If your answer was “Yes,”
does the combined weight
of you and the mobility aid
exceed eight hundred (800) pounds?
Please note that the Handi-Van lift can
accommodate weight up to eight hundred (800) pounds.
PERSONAL TRAVEL ASSISTANCE
Do you at least sometimes require the assistance of a personal care attendant
(family member, friend, aide, etc.) in order to access/use the Handi-Van or to
help you at you at your destination?
If you checked “Yes,” explain what help you might need from another person in order to
access/use the Handi-Van or at your destination.
____________________________________________________________________________________
____________________________________________________________________________________
CERTIFICATION MUST BE ENDORSED BY APPLICANT OR AUTHORIZED SIGNATORY
I, the undersigned applicant (or authorized signatory thereof), do hereby state that the information contained herein
is true and complete. I am aware that the Town of Smithtown Handi-Van provides only minimal ambulatory
assistance. In the event that my condition changes such that recertification by the Town of Smithtown Office for
People with Disabilities is necessary, I understand and agree to fully cooperate with the Town of Smithtown Office
for People with Disabilities in obtaining any and all medical information required from my physician regarding my
medical diagnosis and/or treatment as well as any disability restrictions. This includes the completion and signing
of any and all forms necessary for the release of medical records from my physician regarding my medical
diagnosis and/or treatment as well as any disability restrictions. I understand that all information will be held in
strict confidence and will be used solely to enable the Town of Smithtown Office for People with Disabilities.
Signature
Date
Remember to sign the Certification and have a health care professional complete PART 2.
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TOWN OF SMITHTOWN
OFFICE FOR PEOPLE WITH DISABILITIES
HANDI-VAN ENROLLMENT APPLICATION
PART 2 (Professional Verification of Disability) Page 1 of 2
Your patient is applying to use the Town of Smithtown Handicapped Accessible Transportation on the basis that
he/she is disabled. This form is to be completed by a health care professional who is familiar with the applicant,
his/her disability, and his/her functional abilities. The information you provide will allow the Town of Smithtown to
make an appropriate evaluation of this application and specific trip requests. Please fully answer all questions that
apply to this applicant since an incomplete application will delay the enrollment process.
If you are submitting this form directly on behalf of the applicant, please mail to: Town of Smithtown, Office for
People with Disabilities, 65 Maple Ave, Smithtown, NY 11787. If you need additional information, please
telephone (631) 360-7642 or fax (631) 360-7640.
Applicant’s Name
Applicant’s Address
MEDICAL CONDITION----What is the specific disability or impairment-related condition?
______________________________________________________________________________
Is this condition temporary?
If “Yes”, expected duration until: ____________
Can the applicant climb three 12-inch steps without the assistance of another
person?
Yes
No
Sometimes
Can the applicant wait outside without support for ten minutes?
Yes
No
Sometimes
Can the applicant get in and out of his/her home without the assistance of
another person?
Yes
No
Sometimes
Can the applicant get to and from the curb or pavement edge without the
assistance of another person?
Yes
No
Sometimes
Can the applicant be transported safely in a seated position?
Yes
No
Sometimes
Yes
No
PART 2 (Professional Verification of Disability) Page 2 of 2
Please indicate what, if any, mobility
aids are used by the applicant:
Does the applicant require the assistance of
a personal care attendant in order to access/use
the Handi-Van, or to help the applicant at
his/her destination?
Are you aware of any behavioral abnormalities
exhibited by the applicant that could cause
him/her to possibly harm him/herself, other
passengers, or the bus driver?
If “Yes,” please explain:
Is there any other effect of the disability
of which Office for People with Disabilities
should by aware?
If “Yes,” please explain:
If the applicant has a cognitive disability, is
he/she able to:
Give addresses and phone numbers upon request?
Recognize a destination or landmark?
Deal with unexpected situations or unexpected
change in routine?
Ask for, understand, and follow directions?
Safely and effectively travel through crowded
and/or complex facilities?
IF the applicant has a visual impairment:
Visual acuity Visual
with best correction fields
Left Eye Left Eye
Right Eye Right Eye
Both Eyes Both Eyes
I also certify that the medical information provided in the application is accurate to the best of my knowledge and is consistent
with the applicant’s medical diagnosis.
Signed this _______________day of _______________________________, 20____
(Name of Physician)
Please place Medical office stamp here
(Signature of Physician)
(License Number)
(Phone Number)
(City) (State) (Zip)
PLEASE NOTE: ONLY THE ORIGINAL FORMS OF THIS DOCUMENT WILL BE ACCEPTED.
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HANDI-VAN ENROLLMENT APPLICATION (Town of Smithtown)

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Completed 16 July 2020

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