Fillable ParatransitProgramApplication City of Hayward (Measure B) Paratransit Program

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ParatransitProgramApplication City of Hayward (Measure B) Paratransit Program

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Department of Library and Community Services
Community Services Division
777 B Street, Hayward CA 94541-5007
Tel: 510/583-4250 Fax: 510/583-3650
CITY OF HAYWARD (MEASURE B) PARATRANSIT PROGRAM
A Program Designed to Supplement and Complement the
East Bay Paratransit Service System
Application Information
Thank you for inquiring about the City of Hayward Paratransit Program. You
must complete and return this application in order to enroll. Attached are two
forms: Medical Statement Form and Paratransit Application Form.
The Medical Statement Form must be completed by a medical professional.
Medical statement forms are required for riders 18-70 years of age. If you are
70 years or older, the medical statement form does not need to be completed.
You need to complete only the Paratransit Application Form.
Completed forms should be returned to:
Mail: Hayward City Hall
Paratransit Program
777 B Street
Hayward, CA 94541
Email: Rachael.McNamara@hayward-ca.gov
Fax: (510) 583-3650
NOTE: East Bay Paratransit is the primary ADA mandated paratransit service
for Hayward and Alameda County. You must apply directly to East Bay
Paratransit to enroll. Call 1-800-555-8085 for more information.
If you have any questions regarding the enclosed information, please feel free
to call our office at (510) 583-4230.
18-69
paratransit@hayward-ca.gov
City of Hayward
Paratransit Program Medical Statement Form
Dear Physician:
The person named below would like to participate in the City of Hayward Paratransit Program. This is a transportation
service designed for those unable to utilize other public transit services. In order for the application to be complete, a
medical certification form describing the person’s functional transportation limitations is required. All information
provided below is confidential and is used for the sole purpose of establishing eligibility for the City of Hayward
Paratransit Program. Please help us to determine the certification status of this individual by providing the information
required.
Applicant’s Name_____________________________________________________________
Med. Ins. Coverage_________________________________ Med Ins. #_________________
Please check all of the items below which apply to this applicant
I. Because of a medical and/or disabling condition, the above named person is unable to :
A. Get to a fixed route or wheelchair lift equipped transit service (ex: bus, BART).
B. Board from a standard public transit vehicle (ex: bus, BART).
C. Wait for, or stand in, a moving transit vehicle (ex: bus, BART).
D. See, read and/or comprehend information signs, schedules, maps, etc.
E. Hear and/or comprehend verbal information given by a public transit personnel.
F. Get to, in and out of a taxi vehicle without assistance.
G. Use regular public transportation services because: ________________________________
H. Drive an automobile. When will the applicant be able to drive again? (date)_______________
I. Use East Bay Paratransit services because: _____________________________________
II. Nature of applicant’s condition:
A. Diagnosis:
Is this applicant’s condition: Permanent? _____ Temporary? _____
If temporary, for how long?
B. Does the above named applicant use a wheelchair? YES ______ NO ______
C. Does the person use other assistive devices to ambulate or mobilize? (Describe)
D. Are paratransit services needed by the above named person to obtain a life sustaining treatment?
(ex: dialysis, chemotherapy, radiation therapy, etc.) YES ______ NO ______
E. If doctor’s visits are required: How often? ______________ Until when? (date) ___________
F. If therapy is required: How often? ______________ Until when? (date) ___________
III. Physician’s Statement:
I hereby state that the information provided above is correct. Date_________________
Physician’s Name: Print ___________________________ Signature
Address: Phone # Fax # _______________
RETURN TO: City of Hayward, Paratransit Program
777 B Street, Hayward CA 94541
Tel: (510) 583-4230 Fax: (510) 583-3650
Email: Rachael.McNamara@hayward-ca.gov
paratransit@hayward-ca.gov
City of Hayward, Paratransit Program
777 B Street, Hayward CA 94541
Tel: (510) 583-4230 Fax: (510) 583-3650
Email: paratransit@hayward-ca.gov
Paratransit Application Form (rev. 7/13/11)
*Name:
Last Name First Name Middle Initial
*Daytime Phone: ( ) *Cell Phone: ( )
*Evening Phone: ( ) *TDD/TTY: ( )
*Home Address:
Street Address Apt. # City Zip Code
*Name of Housing Facility (if applicable):
*Birth Date: / / *Male *Female
Month Day Year
*Do you manage your own affairs and deal with your own mail? Yes No
*If “No,” to whom should correspondence be mailed?
*Name: *Relationship:
*Daytime phone: ( ) Cell or Evening phone: ( )
*Mailing Address:
(If different from above) Street Address or PO Box Apt. # City State Zip Code
*Do you (or your care giver) wish to receive your introduction packet and future changes by
e-mail? (Please note vouchers will still be mailed to you):
Yes No
*If “Yes”, please provide your (or your care giver’s) e-mail address so we can send
you the information:
______________________________________________________________________
1. Are you on any of the following forms of income/benefit assistance? (check all that apply)
Supplemental Security Income (SSI) Medi-Cal General Assistance (GA)
Cash Assistance Program for Immigrants (CAPI) CalWorks
2. Gross Individual Monthly Income:
3. Gross Household Monthly Income: # of people in household: __
4. *What is your living arrangement? Live alone Live w/ spouse/partner
Live with adult children Live in a skilled nursing facility/nursing home
Live in assisted living/residential care home Other:
Please complete all questions marked with an asterisk (*).
5. What is your race/ethnicity? African American Asian/Pacific Islander
Caucasian Hispanic/Latino Native American
Other:
6. *What language(s) do you speak? Preferred Language:
Other Language(s):
7. *How do you currently travel to your most frequent destinations? (Check all that apply)
ADA Paratransit (i.e. East Bay Paratransit, Wheels Dial-A-Ride, Union City Paratransit)
Drive myself Someone drives me Buses/BART Taxi
Other:
8. *Have you been certified as eligible for rides with an ADA paratransit service?
(i.e. East Bay Paratransit, Wheels Dial-A-Ride, Union City Paratransit)
Fully eligible Conditionally eligible Rider Identification #:
Not eligible/Denied Have not applied Don’t know
9. *Do you use any of the following mobility aids or specialized equipment?
Cane White Cane Walker
Manual Wheelchair Power Wheelchair Power Scooter
Service Animal Portable Oxygen Tank Other:
10. *Do you need a wheelchair lift to get in and out of a vehicle? Yes No Don’t know
11. *Do you typically travel with assistance from another person? Yes No
12. *Please describe your disability or disabling health condition and explain how this
condition prevents you from using public transit (i.e. buses or BART):
13. *Is the above condition you describe: Permanent Temporary until:
14. How often do you expect to use paratransit? ___ Daily ___ 2-4x week ___ 2-4x month
15. *Emergency Contact Person:
Relationship to you: *Daytime phone: ( )
Cell phone: ( ) Evening phone: ( )
16. *If you need future information provided to you in an accessible format, please check
which format you prefer: Large Print Audiotape Braille CD/Electronic File
I certify that the information in this application is true and correct. I understand that knowingly falsifying the
information will result in denial of service. I give the City permission to verify whether I am enrolled with
East Bay Paratransit, Wheels Dial-A-Ride or Union City Paratransit. I understand that all application
information will be kept confidential, and only the information required to provide the service I request will be
disclosed to those who perform the services.
*Applicant’s Signature: *Date:
Name of Person who assisted you with application/Phone #:
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ParatransitProgramApplication City of Hayward (Measure B) Paratransit Program

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Completed 11 July 2020

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