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