Trial Sun Van Application for Paratransit Service

Applicant Contact Information

Residential Street Address   (no PO Boxes)

Apartment No./Space No. Please provide all information about your home number, if applicable.

Building Complex Name or Building No. Please provide all information about your building, if applicable.

Gate Code Please provide all information about gate access, if applicable.

City, State, Zip Code  

Primary Phone Number   Please include area code (e.g. 505-555-5555).

Secondary Phone Number Please include area code (e.g. 505-555-5555).

Work Phone Number Please include area code (e.g. 505-555-5555).

Your E-Mail Address  

About You

Date of Birth   Month/Day/Year e.g. 01/20/1980

Gender

Male
Female
Other

Prefered Language English Español Tiếng Việt 中文 Français kiswahili Kinyarwanda فارسی دری 한국어 Other

Emergeny Contact Information

Relationship to Applicant  

Primary Phone Number   Please include area code (e.g. 505-555-5555).

Secondary Phone Number Please include area code (e.g. 505-555-5555).

Healthcare Professional Contact Information

First Name, Last Name, Title (e.g. MD, NP, PA).  

License/Certification number

Specialization  

Street Address   Street and number.

City, State, Zip Code  

Phone Number Please include area code (e.g. 505-555-5555).

Fax Number Please include area code (e.g. 505-555-5555).

Disability & Health Condition Information

What disability have you been diagnosed with?   (600 words or fewer)

Date of Diagnosis   Month/Day/Year e.g. 01/30/1980

Does your disability PREVENT you from using the regular bus?  

Yes
No

If yes, please explain. Please explain how your disability prevents you from using the regular bus. (600 words or fewer)

Which of the following best describes your conditions?  

Permanent
Temporary
I don’t know

If temporary, how long do you expect the condition to continue?

Does your disability change from day to day or seasonally?  

Yes
No

If yes, please explain. (600 words or fewer.)

Do the conditions you describe change from day-to-day in a way that affects your ability to ride the regular bus service?  

Yes, good on some days, bad on others
No, doesn’t change
I don’t know

Does your disability make it difficult for you to understand and remember how to find your way to and from the bus stop?

Yes
No

If yes, please explain. (600 words or fewer.)

Mobility Information

Do you currently use any mobility aids or specialized equipment?  

Yes
No

If yes, please select all that apply.

Brace(s)

Manual Wheelchair

Scooter

White Cane

Prosthesis

Crutches

Cane

Motorized Wheelchair

Service Animal

Walker

Portable Oxygen

Communication Board/Devices

Other

If other, please specify.

How many city blocks can you travel with your usual mobility aid and without the help of another person?  

Current Travel Information

How do you currently travel to your frequent destinations?   Please check all that apply.

Buses

Sun Van

Taxi

Someone takes me

Other

Certification

Applicant Certification

I understand that the purpose of this application is to determine if I am eligible for Sun Van’s Paratransit services.

I certify that I have been truthful in answering this form and that the information that I have provided is correct to the best of my knowledge.

I understand that falsification of this information could result in a loss of Paratransit service.

I agree to notify Sun Van if I no longer need to use Paratransit service.

Authorized Representative Certification Please check the box and fill this section if this form was completed by an authorized representative.

I verify that I am authorized to represent the applicant stated in this application. Please enter your name and relationship to applicant below.

Authorized Representative First and Last Name If you are authorized to represent the applicant stated in this application, please state your first and last name.

Authorized Representative Relationship to Applicant If you are authorized to represent the applicant stated in this application, please state your relationship to the applicant.