Paratransit Application Application for Paratransit "*" indicates required fields Step 1 of 9 11% General Information: Please read carefully. All questions must be answered. Applications that are incomplete or lack required signatures will be returned.This application is for:* New permanent eligibility (3 years) Recertification (3 years) New temporary eligibility (maximum 12 months) Applicant's Name* First Last Home Address* Street Address Unit/Apt # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred method of contact:* Mail Phone Email Mailing Address (if different) Street Address Unit/Apt # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Date of Birth* Month Day Year Language of choice:Emergency contact:* First Last Relationship to applicant:*Email* Emergency telephone:*Additional contact:Do you receive medical services under the Oregon Health Plan (OHP)?* Yes No Unsure Are you currently eligible for transportation under the Medicaid program?* Yes No Unsure Yamhill County transit agents and employees will use the information provided during the application process for the purpose of determining eligibility and providing transportation servicesSection 1Please tell us what you know about the local bus service offered by Yamhill County Transit1. Have you ever tried to use the local bus service that Yamhill County Transit (YC Transit) operates throughout McMinnville and Newberg? Yes No 2. Are you aware that all YC Transit buses are fully accessible to accommodate persons who use wheelchairs or who are unable to climb the bus steps? Yes No 3. Are you able to reach the YC Transit bus stop nearest your home? Yes No Sometimes Please explain:4. What best describes your ability to use the local bus service?* I can use the YC Transit bus service for most of my transportation needs I have never attempted to use the YC Transit bus service I could use the YC Transit for specific routes/destinations. I cannot use YC Transit bus service with the help of a personal care attendant (PCA) I cannot use YC Transit bus service at all. Please explain: Paratransit sometimes provides connecting service to the nearest YC Transit bus stop, shelter, or transit station when the distance to the bus stop is what prevents the rider from being able to use the bus.5. If paratransit were to provide transportation for you to the YC Transit bus stop closest to your home, please check all the statements that would apply to you:* I can wait at a bus stop for a YC Transit bus Due to the nature of my disability, I must wait indoors during inclement weather. Due to the nature of my disability, I am able to wait only if there is a covered shelter. Due to the nature of my disability, I am never able to wait at a YC Transit bus stop on my own. Other Please explain in further detail:6. Are there any other reasons why you cannot board or ride a YC Transit bus?* Yes No No, but prefer not to Please explain: Section 2Please provide the following information about your disability1. What is the primary disability or health condition(s) that limits your mobility and ability to use YC Transit bus service? (Please be specific.)*2. Do you have other physical, mental, or emotional disabilities or conditions that limit your ability to use YC Transit bus service? Yes No Please explain:3. Do the effects or symptoms of your disability vary from day to day? Yes No Please explain:4. Is your disability or condition:* Permanent Temporary What is your estimated recovery period?Month(s)Year(s) Section 3Mobility Equipment1. Indicate which mobility equipment you presently use and would be using when traveling on YC Transit:* NONE OTHER Cane White Cane Crutches Walker Orthotic device Lift mechanism Manual wheelchair Power wheelchair Power scooter Extended footrests Chest restraint Wheelchair only to board bus Service animal Picture/Alphabet board Portable oxygen Respirator Prosthetic device Please describe:2. Under what circumstances would you travel with your manual wheelchair?2. Under what circumstances would you travel with your power wheelchair or scooter?3. If you use a manual or power wheelchair or scooter, do you want to transfer to a seat from your device when riding on YC Transit buses? Yes No Sometimes Please explain:4. Is the combined weight of you and your wheelchair or scooter more than 600 lbs.?* Yes No Don’t KNow 5. Paratransit operators are unable to perform the duties of a Personal Care Attendant (PCA). Will you need to travel with a PCA or somone to assist you when you travel on paratranit? (Attendants travel free when assisting passengers)* Always Sometimes Never 6. How does a PCA or attendant assist you?* All activities of daily living To help me get to the vehicle when it arrives By pushing my manual wheelchair To help me get to my destination from the vehicle Other Please explain: Section 4Please provide the following information about your functional capabilities1. How far are you able to travel on a flat surface, whether on your own or using your regular mobility aid, without the assistance of another person?* Not able to travel at all without assistance from another person Severely restricted, only at home Less than half a city block One (1) city block Two (2) city blocks Three (3) city blocks One-half (1/2) mile (about six city blocks) Three-quarters (3/4) mile (about nine city blocks) or more 2. Can you climb three (3) 12-in high steps?* Yes No Please check the environmental conditions that affect your ability to get to and from a YC Transit bus stop, or to and from a destination using the YC Transit Bus.Due to the nature of my disability, to travel, I must:* Avoid inclines Be on sidewalks Avoid steep hills Avoid hours of darkness Please explain:Due to the nature of my disability, all intersections in my path must have:* Curb cuts A clearly marked crosswalk Must have both a crosswalk and a traffic signal Other Please explain:3. Please check the specific weather conditions that, combined with your disability, prevent you from YC Transit bus service: snow ice rain heat above a specific degree Fahrenheit cold below a specific degree Fahrenheit Please provide the specific degree:Please explain how these conditions would affect your ability to get to or from a YC Transit bus stop to your destination and/or home: Section 5How might you use YCT Transit ParaTransitIf you are eligible for paratransit services for some or all trips, what would be your most frequent destination? Please provide building names and/or addresses below if possible:* Doctor offices Grocery stores Pharmacies Other Select AllBuidling Names and/or AddressesIf you are determined eligible for paratransit services, would you be interested in a once-a-week grocery shopping program? Yes No If you are unable to carry all your own purchases when grocery shopping, the operator on a Paratransit Shopper is able to aid carrying groceries on and off the bus. Regular paratransit operators will not be able to carry parcels for you.) Section 6Optional Information The following questions are optional and will have no bearing on your eligibility for Yamhill County Transit Paratransit service:What is your ethnicity? African American Asian/Pacific Islander Caucasian Hispanic/Latino Native American Other What is your gender? Female Male Non-binary Other Are you a US Veteran? Yes No How did you find out about YC Transit paratransit service? Section 7Please read and sign the following:Application Requirements* I agree to the application terms and conditions included below.I understand that the purpose of this application is to determine whether I am eligible to use Yamhill County Transit paratransit services. I certify that the information in this application is true and correct. I understand that providing false or inaccurate information may result in denial of service as well as penalty under the law. I understand that information I provide will be disclosed only as needed to evaluate eligibility for Yamhill County Transit paratransit, and to provide paratransit services if I am determined to be eligible, unless I give other specific authorization. I understand that I might be asked to provide additional information necessary for a proper determination of eligibility for paratransit services.Name* First Last Applicant's Signature*Person completing this form, if other than applicant:Name First Last Relationship to applicant:SignatureDate Month Day Year PhoneEmail CAPTCHA
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