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Part 3. Information About the Applicant’s Disability

1. What types of disabilities prevent you from using Palm Tran buses? (Check all that apply)

Physical Disability Developmental Disability Diagnosis of Alzheimer Di

sease

No usable vision Mental Illness End-Stage Kidney Disease

Multiple Severe Disabilities Age 70 and older (CSTS only)

Age 85 and older

Please describe your disability in more detail:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2. Is the disability described above temporary or permanent? Temporary, I expect it to last for another ________months Permanent I don’t know

3. Please indicate below if you use any of the following mobility aids or equipment.

Cane Crutches Leg Braces Walker

Manual Wheelchair Powered Wheelchair Powered Scooter/Cart White Cane (blind)

Sighted (person) Guide Optical Devices (telescope, light, special glasses, etc.)

Portable Medical Equipment (oxygen tank, etc.) O t h e r ( p l e a s e s p e c i f y ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

I don’t use any of the above mobility aids or equipment

Note: Palm Tran CONNECTION may not be able to accommodate you if your wheelchair/ scooter is longer than 48 inches or wider than 30 inches or if your total weight when occupy- ing your wheelchair exceeds 600 pounds.

Per the Americans with Disabilities Act (ADA), complementary paratransit is not intended to be a comprehensive system of transportation for individuals with disabilities.

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