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ADA Application The information obtained from this registration packet will be used by the Augusta Public Transit ADA Office to determine eligibility for Complimentary Paratransit Services and to ensure timely and accurate analysis of trip requests. (Please Print Or Type All Information) 1. Name 2. Street Address 3. Do you live within the city limits of Augusta? Yes No 4. County City Zip Code 5. Nearest cross street/intersection 6. Phone Numbers: (Home) (Work) (TDD) 7. Social Security Number 8. What is your disability? 9. Is your disability temporary? YES NO If yes, expected duration? 10. Please check each mobility aid that you use: Manual Wheelchair Electric Wheelchair Powered Scooter Cane Crutches Dimensions of Wheelchair/Scooter: (Width in inches) (Length in inches) (Estimated Weight in pounds when occupied) Walker Guide Dog White Cane Other 11. Will someone ride with you to your appointments? Yes No 12. How far can you travel without the assistance of another person? Feet 13. Can you climb three 12-inch steps without assistance? Yes No Sometimes ---PAGE BREAK--- 14. Can you wait outside 10-15 minutes without the assistance of another person? Yes No Sometimes 15. Please tell us anything else about your disability that you feel we need to know in order to help determine your eligibility. I hereby certify that the information given about me is correct and I understand that any intentionally false or misleading information is grounds for denial of Paratransit Services. Signature of Applicant Date If this application was filled out by someone other than the applicant, that person must complete the following information: Name Relationship to Applicant Address Apt/Suite City State Zip Code Phone Number (Include Area Code) Signature Date ---PAGE BREAK--- ****This Page To Be Filled Out By A Health Care Professional**** Name Name of Facility or Agency Address Room/Suite_________ City State Zip Phone Number Fax Signature 1. What is the applicant's disability? 2. Is this disability temporary? Yes 3. Does the applicant require an attendant while traveling? Yes 4. How far can the applicant travel without the assistance of another person? 5. Can the applicant climb three 12 inch steps without assistance? Yes No Sometimes 6. Can the applicant wait outside for 10-15 minutes without the assistance of another person? Yes No Sometimes 7. How does the disability affect the applicant's mobility? 8. Does the disability prevent the applicant from using current bus system? Yes