| Main Menu General Information Eligibility Printable Application |
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ADA Paratransit Certification Application Page 2 of 6 |
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The following information will be used to ensure that an appropriate vehicle is utilized to provide your transportation and that an accurate analysis of your trip request can be made by Fort Wayne Citilink.
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| 8. Do you use any of the following aids for mobility? (Check all that apply)
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| Manual wheelchair______ Electric wheelchair _________ |
| Powered scooter_______Cane ______ Crutches _________ |
| Personal care attendant _______________Guide dog _____________
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| 9. Do you require a Personal Care Attendant when you travel using public transit. _________
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| Can you travel 200 feet without the assistance of another person? Yes _____No ______ Sometimes _____
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| Can you travel 1/4 mile without the assistance of another person? Yes ________ No _____ Sometimes _____
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| Can you travel 3/4 mile without the assistance of another person? Yes________No _____Sometimes______
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| Can you climb three 12-inch steps without assistance? Yes______ No_______ Sometimes ___________
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| Can you wait outside without support for ten minutes? Yes _______No _______ Sometimes __________
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| Can you wait outside without support for ten minutes? Yes _______No _______ Sometimes __________
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I hereby certify that the above information is correct. Signed: ________________________________________________________________ Date: _________________________________________________________________ |