Application for ADA Paratransit Eligibility
Please complete ALL sections of this form. An incomplete application will be returned. The information you provide will help determine what type of transportation service is the right service for you. All information will remain confidential. Please use black or blue pen only. Additional postage maybe required
Download PDF Form
APPLICANT INFORMATION (PLEASE PRINT)
First Name
(Required)
Middle Initial
Last Name
(Required)
Mailing Address
(Required)
Apt#
City
(Required)
State
(Required)
Zip
(Required)
Country
(Required)
Phone
Cell
TTY for hearing impaired
Home Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Cross Street
(Required)
Name of Facility/Apartments
(Required)
Gate Code
(Required)
Email
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Sex
(Required)
Male
Female
Please send me written information in an alternate format.
Large Print
Audio Tape
Braille
CD
Other
Español(Spanish)
中文(Chinese)
Русский(Russian)
tiêng Việt(Vietnamese)
Please provide the name of a LOCAL relative/friend in case of an emergency:
Name
(Required)
Relationship
(Required)
Phone (home)
(Required)
Cell
(Required)
The Sacramento Regional Transit District’s Service Area
SacRT GO ADA paratransit service area is designed to be “comparable” to SacRT’s fixed-route bus and light rail service, providing service to locations within a ¾ mile radius of SacRT’s bus routes or light rail stations during regular service hours. This includes areas within Antelope, Elverta, Carmichael, Citrus Heights, Fair Oaks, Folsom, North Highlands, Orangevale, Rancho Cordova, Rio Linda, Sacramento and unincorporated areas of Sacramento County. SacRT E-van paratransit service goes to Elk Grove. SacRT GO paratransit service does not go to West Sacramento or Roseville with the following exceptions:
Roseville: SacRT GO is able to transport passengers who live in Citrus Heights to the Kaiser Permanente Roseville facilities located at Riverside and at Eureka, and to the Sutter Roseville Medical facilities if you are unable to transfer to a Roseville ADA paratransit vehicle.
There are also transfer points, which can connect passengers to other ADA paratransit services provided in adjacent jurisdictions. Reservationists will provide assistance in arranging your trip to connect at a transfer point, if needed. Reservationists will provide assistance in arranging your trip to connect at a transfer point, if needed.
1. How did you hear about ADA paratransit?
(Required)
2. Why are you applying for ADA paratransit service?
(Required)
3. What is the main disability or health condition that prevents you from being able to use SacRT’s regular bus or light rail trains? Please be specific (for example: stroke, visual impairment, cognitive impairment, emphysema, schizophrenia, etc.).
(Required)
4. Do you have other physical, cognitive, visual or mental health disabilities or conditions that limit your ability to use SacRT’s regular bus or light rail trains?(Required)
Yes
No
If yes, please explain:
(Required)
5. When did you first experience the conditions you described above?
(Required)
0-1 year ago
1-5 years ago
Longer than 5 years
6. Is your disability temporary?
Yes, I expect it to last _______months.
No, it is permanent
I don’t know
Enter amount of months
(Required)
7. ADA paratransit drivers are unable to perform the duties of a Personal Care Attendant (PCA). Do you need to bring someone to assist you when you travel outside your home? (For example, to push your wheelchair, carry oxygen, etc.)? We do not provide a PCA to riders. If you need assistance beyond what the ADA paratransit driver can provide, please bring someone with you.
Yes; always
Yes; sometimes
No; never
8. How does that person help you complete the purpose of your trip?
(Required)
9. Are you able to wait for a regular SacRT bus or light rail train?
(Required)
Yes
No
10. If you checked no, you must explain in the space below, how you are prevented from waiting for a bus or light rail train.
(Required)
11. How far can you walk on level ground?
_____feet
Less than 1 block
1 block
2 block
3 or more block
Enter amount of feet
(Required)
12. If using a mobility aid, how far are you able to go without help from someone else?
_____feet
Less than 1 block
1 block
2 block
3 or more block
Enter amount of feet
(Required)
MOBILITY AID AND/OR EQUIPMENT INFORMATION
If you use a power wheelchair, or scooter, SacRT will need to verify what you and your wheelchair weigh together. Many power wheelchairs and scooters are very heavy. (SacRT ADA paratransit vehicle lifts are designed to lift 600 to 800 pounds, depending on the ADA paratransit vehicle type.) Which of these mobility aids do you currently use when traveling? Please check all that apply to you.
DO NOT SELECT A DEVICE THAT YOU ARE WAITING ON FOR APPROVAL OR PRESCRIPTION
manual wheelchair
support cane
crutches
leg brace
service animal
powered wheelchair *
powered scooter/cart *
portable oxygen
power assist wheelchair
white cane (for visual impairments)
walker
walker with seat
prosthesis
communication board
other (please specify
no mobility aid (skip to page 5)
* The ADA defines a “Wheelchair” as a mobility aid belonging to any class of three- or more-wheeled devices, usable indoors, designed or modified for and used by individuals with mobility impairments, whether operated manually or powered.
If you checked manual wheelchair, power wheelchair, or powered scooter/cart, please provide the following information:
Are you able to propel and /or control your wheelchair or scooter without help
Yes
No
Do you and your wheelchair weigh more than 600 pounds combined?
(Required)
Yes
No
What is the make/model of your wheelchair or scooter?
Make
(Required)
Model
(Required)
HOW DO YOU TRAVEL NOW?
Please check all that apply to you.
(Required)
walk
drive a car
ride in someone’s ca
taxi
bicycle
ADA paratransit
SacRT bus
SacRT light rail train
Other
Do you use SacRT's regular buses and/or light rail trains by yourself?
Yes
No
If yes, how often?
(Required)
Which routes do you use?
(Required)
When did you last use SacRT on your own
(Required)
Have you ever had training on how to travel around the community or how to use SacRT’s accessible regular buses or light rail trains?
Yes
No
Never ridden bus/light rail
I am interested in travel training
Never want to ride bus/light rail
If you checked “yes”, please note when and where you received this training.
FUNCTIONAL ABILITIES: USING REGULAR BUSES AND LIGHT RAIL TRAINS
What best describes your functional ability to use the regular buses and light rail trains on your own?
(CHECK ALL THAT APPLY)
(Required)
I can get to and from bus stops/stations if the distance is not too far
Because of my disability or medical condition, I have difficulty understanding or remembering all the things I would have to do to use the regular buses and light rail trains.
I can use the regular buses and light rail trains if it is some place I go all the time
I have a visual impairment that causes me to be unable to use the regular buses or light rail trains at times. If checked, please explain how and when your visual impairment prevents you from using fixed route service independently:
I am not able to use the regular buses and light rail trains by myself for other
Reasons. Please explain
(Required)
checkbox6
I would be able to use the regular buses or light rail trains on my own IF
resons
(Required)
CERTIFICATION OF APPLICANT
I understand the information I provided on this application is true and correct to the best of my knowledge. The purpose of this application is to determine if I am eligible to use ADA paratransit services, or if at times I can ride the SacRT regular buses and light rail trains. I understand that falsification of information could result in a loss of ADA paratransit services as well as a penalty under the law. I also understand that, at no expense to me the Sacramento Regional Transit District
may require that I participate in an in-person functional evaluation of my travel skills and agree to such a functional evaluation, if one is necessary.
I agree to notify SacRT if my condition changes, if my mobility device has been replaced, if I have a new mobility device, or if I no longer need to use ADA paratransit service
(Signature of Applicant)
(Required)
Date
(Required)
MM slash DD slash YYYY
Person Completing Application If Not the Applicant (REQUIRED)
Printed Name
(Required)
Relationship to Applicant
(Required)
Signature
Date
(Required)
MM slash DD slash YYYY
Daytime Phone #
(Required)
Evening Phone #
(Required)
Agency Name (if applicable
(Required)