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Paratransit Application

(Please indicate below the program(s) you are applying for)

Americans with Disabilities Act (ADA County Senior Transportation Service (CSTS) Division of Senior Services (DOSS) Transportation Disadvantaged (TD)

New Application Recertification - Current Client # ________________

In compliance with the Americans with Disabilities Act of 1990 (ADA), Palm Tran CONNECTION (PTC) provides “paratransit” (i.e., van/shared-ride) service to individuals with a disability which prevents traveling via Palm Tran fixed-route bus service. Paratransit service is only for those trips that individuals, because of their disability cannot travel by fixed-route buses.

This application form is intended to determine completing this application form, please read the offered by Palm Tran CONNECTION.

eligibility for paratransit service.

enclosed

Eligibility

Brochure

for

Before

programs

INSTRUCTIONS FOR COMPLETING THIS FORM: The applicant (or someone assisting the applicant) must complete ALL questions. Incomplete forms will not be returned. A licensed physician must complete and sign the MEDICAL VERIFICATION section. All applicants, whether new or new persons applying for recertifica- tion, must complete a new application. If you have questions or need assistance completing this form, please call:

(561) 649-9838 (option 4) 1-877-870-9849 (toll-free) Outside local calling area

  • (561)

    649-0683 TDD

  • (561)

    649-0685 FAX

WHEN COMPLETED, PLEASE RETURN ENTIRE FORM TO: Palm Tran CONNECTION Community Transportation Coordinator 3040 South Military Trail, Suite C Lake Worth, Florida 33463

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