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Placer TART ParaTransit Application

Americans with Disabilities Act (ADA) paratransit service is specialized transportation service for persons who are unable to independently use fixed route bus service, due to a disability or health related condition some or all of the time. Paratransit service is provided by public transportation systems as part of the requirements of ADA.

In order to use ADA paratransit services, you must first be certified as eligible. Please read the following instructions before filling out the attached application form. All information that you supply will be kept strictly confidential.

  1. Please answer FULLY all of the questions on the form, and return it to Tahoe Area Regional Transit (TART). Incomplete applications will not be processed, and will be returned to you for completion.
  2. Your application will be reviewed, and an eligibility determination will made within 21 days of receipt of a COMPLETE application. You will receive a notice as to the terms of your eligibility. If you are determined to be capable of using fixed route bus service, YOU WILL NOT BE ELIGIBLE for ADA paratransit services.
  3. The review will be based on your ability to use fixed route bus service. It may require additional information, such as a phone call, personal interview, or assessment with you, or consultation with your doctor or therapist.
  4. You may be found: 1) Eligible for all of your travel needs on ADA paratransit service (full eligibility) 2) Eligible for some trips on ADA paratransit service (conditional eligibility) depending on the nature of your disability; or 3) Not eligible for ADA paratransit service.
  5. Please note that if your functional abilities change, your eligibility status may also change.
  6. If you are certified as eligible, you will be able to use ADA paratransit services or local fixed routes, depending on any conditional restrictions.
  7. If you do not agree with the decision on your eligibility, you may appeal. Information on how to file an appeal will be included with your notice of eligibility.

Request for Certification of Americans with Disability Act Paratransit Eligibility

The information obtained in this certification process will only be used by Tahoe Area Regional Transit for the provision of transportation services. Information regarding the evaluation of your functional ability to use transit services will only be shared with other transit providers to facilitate travel in those areas. The information will not be provided to any other person or agency.

    1.  Name:______________________________________________________________________
    2.  Address:____________________________________________________________________
      Mailing (if different than above): ___________________________________________________________________________
    3.  Phone: _________________________Home: ______________________________ Alternate: _______________________________________
    4.  Date of birth: ______ /______ /______
    5.  What is the disability which prevents you from using our fixed route bus service?
      ___________________________________________________________________________
      Is this condition temporary?          YES                NO
      If yes, when is it expected to subside? ______ /______ /______
    6. How does this disability prevent you from using fixed route bus services?
      Please explain completely. Use an additional sheet, if necessary.
      ______________________________________________________________________
      ______________________________________________________________________
    7. Are there any other effects of your disability of which we need to be aware?The following information will be used to ensure that an appropriate vehicle is used to provide your transportation and so an accurate analysis of your trip requests can be made by TART.
      _____________________________________________________________________
      ______________________________________________________________________
    8. Do you use any of the following mobility aids? (check all that apply)
      Manual wheelchair ______
      Electric wheelchair ______
      Wheelchair Cane ______
      Guide dog ______
      Other service animal ______
      Crutches ______
      Powered scooter ______
      Personal care attendant ______If you use a wheelchair or scooter, what is it’s:
      length ______ inches           width ______ inchesDoes the total weight of your wheelchair or scooter and yourself exceed 600 Lbs.?
      YES                NO
      *Please note that we may not be able to accommodate wheelchairs or scooters that
      exceed these specifications when occupied: 48 inches in length- 32 inches in width, 600
      pounds (including the individual.)
    9. Do you currently use any transit or paratransit service in the region?
      YES                NOIf yes, please describe: _______________________________________________________________
      ______________________________________________________________________
    10. What is the maximum distance you can travel without the assistance of another person?       ______  yards
    11. Does your disability prevent you from traveling this distance in snow, ice or over certain terrain? (Explain)
      _____________________________________________________________________
      ______________________________________________________________________
    12. Can you climb up and down three 12-inch steps to get on and off a bus?   YES                NO               SOMETIMES
    13. What is the maximum period of time you can wait outside without support?
      ____________________________________________________________________
      ____________________________________________________________________
    14. Is this time period affected by extremes of hot or cold weather?
      YES                NOIf yes, please describe: ____________________________________________________________
      ____________________________________________________________________
    15. I hereby certify that the information given above is correct.
      Signed: _______________________________________________________________
      Dated:  ______ /______ /_____
    16. If this application has been completed by someone other that the person requesting certification, that person must also complete the following:
      Name: ________________________________________________________
      Address:_______________________________________________________
      Phone: _________________________Home: ______________________________ Alternate: ___________________________________
      Signed: _______________________________________________________
      Dated:  ______ /______ /______

Authorization to release personal information
(To be completed by applicant. A doctor’s statement is not required.)

I hereby authorize the release of information to Tahoe Area Regional Transit about my functional travel abilities. The information released will be used solely to determine my eligibility for ADA paratransit service.

Name of professional*: ___________________________________________________________________________________________________________

Agency/Organization:  ___________________________________________________________________________________________________________

Phone number:  _________________________________________________________________________________________________________________

I understand that I have the right to receive a copy of this authorization. I understand that I may revoke this authorization at any time.

Name of applicant (please print):  __________________________________________________________________________________________________

Signature of applicant ________________________________Date _______________________________________________________________________

*Verifying “professional” may be a rehabilitation specialist, disability evaluator, mental
health case worker, physician or other such individual knowledgeable of your disability
or disabilities and functional travel abilities.

 

Return completed application to:
Tahoe Area Regional Transit
(530) 550-1212
PO Box 1909
Tahoe City, CA 96145
Email: [email protected]