Fillable Para Application 4.24.18

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Para Application 4.24.18

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Plea
se review the “Eligibility” section in the
UW
P
aratransit
Service
R
ide
r’s Guide. Disability alone does not
determine paratransit eligibility; the decision is based on the applicant’s functional ability to use the fixed
route transit system and is not a medical decision. Age, inability to drive, convenience, or unavailability of a
fixed route are not taken into consideration when determining eligibility.
To apply for paratransit service, please complete the entire application using as much detail as possible.
Additional information may be required.
Application Date:_______________________ ☐ Renewal
☐ New Application
Personal I
nformation:
First Name: ____________________________
Middle Initial: ____ Last Name:_______________________
Home Address:____________________________________________________________________________
Mailing Address (if different): ________________________________________________________________
Primary Phone: ____________________________ Secondary Phone: _______________________________
Birth Date: _______/_______/_______
(Month) (Day) (Year)
Gender: ☐ MALE ☐ FEMALE
Do you have a personal care attendant (PCA) who assists you iwth daily life functions? ☐ YES ☐ NO
If so, will the PCA need to ride with you on a regular basis? ☐ YES ☐ NO
All
information regarding the
p
aratransit
s
e
rvice is provided in writing unless requested otherwise.
Do you need information in a different format? ☐ YES ☐ NO
If YES, what format: ____________________________________________________
Emergency Contact Information:
Primary Secondary
Na
me: _____________________________________
Name: _____________________________________
Relationship: _____________
__
_________________
Relationship: _________________
_______________
Phone
: ________________________________
_____ Phone
: _________________
____________________
Official
Use
O
nly
PARATRANSIT SERVICE APPLICATION
Phone: (307) 766-6686 / Fax: (307) 766-9804
Date Received: ______________________ Grace Period Expiration Date: ______________________ Clinical Professional Contacted: ______________________
Determination: ☐ Unconditional
☐ Conditional
☐ Denied NOVUS
Letter Sent
Mailing List
Notes:
Eligibility Assessment:
Are you able to ride the fixed route transit system? ☐ YES ☐ NO ☐ SOMETIMES
T
he
fixed route has stop locations throughout Laramie with varying schedules. Please visit www.uwyo.edu/roundup for
m
ore information.
If NO or SOMETIMES: In your own words, please describe why you are unable to ride the fixed route transit system:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
If applicable, what type of disability prevents you from using the fixed route transit system?
Check all that apply:
☐ Physical disability
☐ Developmental/cognitive disability
☐ Health related condition
☐ Visual Impairment/blindness
☐ Mental disorder
☐ Other, please explain: _____________________________
My disability is: ☐ Permanent ☐ Temporary, and expected to last until:____________________________________
Are you able to get on and off a fixed route bus? ☐ YES ☐ NO ☐ SOMETIMES ☐ I DON’T KNOW
IF NO or SOMETIMES, please explain:
_________________________________________________________________________________________
_________________________________________________________________________________________
Can you get to a seat or wheelchair position by yourself? ☐ YES ☐ NO ☐ SOMETIMES ☐ I DON’T KNOW
IF NO or SOMETIMES, please explain:
_________________________________________________________________________________________
_________________________________________________________________________________________
Please check all of the mobility aids or equipment that you may use while riding the bus:
☐ Cane
☐ Crutches ☐ Walker
☐ Service animal
☐ Leg braces ☐ Knee walker
☐ Long white cane
☐ Oxygen tank
☐ Common manual wheelchair: Combined weight of person and wheelchair: __________lbs.
☐ Common electric wheelchair: Combined weight of person and wheelchair: __________lbs.
☐ Oversized electric wheelchair: Combined weight of person and wheelchair: __________lbs.
☐ Common scooter: Combined weight of person and scooter: _________lbs.
☐ Oversized scooter: Combined weight of person and scooter: _________lbs.
☐ Other device(s), please specify: __________________________________________________________
Please see the Wheelchair/Scooter section in the UW Paratransit Service Rider’s Guide for additional definitions.
How far can you travel by foot or by using a mobility aid? Check all that apply:
To the ground outside my home ☐ Can ☐ Cannot
To the curb in front of my home ☐ Can ☐ Cannot
Up to 3 blocks (1/4 mile) ☐ Can ☐ Cannot
Up to 6 blocks (1/2 mile) ☐ Can ☐ Cannot
Up to 9 blocks (3/4 mile) ☐ Can ☐ Cannot
If applicable, please detail why you are unable to travel certain distances:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
In order for us to serve you better and ensure your safety we ask that you inform us about conditions which might affect
you while on a paratransit vehicle. Or, in the event of an emergency or accident, if there is anything the driver should
NOT do to lend assistance. If you choose to answer this, please use the space below.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Trip Notifications:
Standard carrier rates may apply. See the Paratransit Service Rider’s Guide for additional information.
Would you like to receive automated text messages when your bus is about to arrive? ☐YES ☐NO
If YES, please use this cell phone number: _________________________________________________________
Would you like to receive email notifications regarding your rides and service updates? ☐YES ☐NO
If YES, please use this email address: _____________________________________________________________
Account Access:
Please list any individuals you wish to have access to your paratransit account (including, but not limited to, personal
information and rides):
______________________________________________ ______________________________________________
______________________________________________ ______________________________________________
Did you need help completing this application? ☐ YES ☐ NO
IF YES, please complete:
Name: __________________________________ Phone Number:______________________________________
Address: ____________________________________________________________________________________
Relationship to you: ______________________ Agency (if applicable):__________________________________
Applicant Signature: I certify that the information on this document is correct. Date
Guardian/POA Signature (if applicable): I certify that the information on this document is correct.
Date
Please be sure to complete the attached waiver; step 2 of the application process.
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This release form is valid for ninety (90) days. An additional release form may be requested if additional verification is
needed.
Application Date:_____________
Applicant’s Personal Information:
First Name:____________________________ Middle Initial: ____ Last Name:___________________________
Home Address:________________________________________________________________________________
Mailing Address (if different):_____________________________________________________________________
Primary Phone:________________________________________________________________________________
Secondary Phone:______________________________________________________________________________
Birth Date: _______/_______/_______
(Month) (Day) (Year)
Gender: ☐ MALE ☐ FEMALE
Clinical Professional’s Information:
A clinical professional is a licensed individual that has the ability to diagnose and treat medical and mental conditions.
Name: ___________________________________________ Title: _______________________________________
Business Name: _______________________________________________________________________________
Mailing Address: ______________________________________________________________________________
Phone Number: ________________________________ Fax Number: ____________________________________
I authorize the listed clinical professional to release information to UW Transportation Services representatives as it
pertains to my application for paratransit service. I agree that UW Transportation Services may request written and/
or verbal verification for my application for paratransit service.
Applicant Signature: Date
Guardian/POA Signature (if applicable): Date
PARATRANSIT SERVICE RELEASE FORM
Phone: (307) 766-6686 / Fax: (307) 766-9804
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Para Application 4.24.18

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Completed 1 June 2020

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