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Because of my disability I can never use the accessible fixed-route city buses. I understand that the purpose of this evaluation form is to determine if there are times when I cannot use the accessible fixed-route city bus service provided by StarTran and must therefore use the HandiVan service. To fill out form tab to each field. Print form when complete. HandiVan Application To be completed by applicant GENERAL INFORMATION Name Address Phone City/State/Zip Birthdate Social Security Emergency Contact Name Phone Relationship APPLICANT S CERTIFICATION Please indicate the reasons why you are seeking ADA paratransit eligibility check all that apply I can use accessible fixed-route city buses to go some places but in certain circumstances I cannot use accessible fixed-route city buses. I understand that the information about my disability contained in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility. I certify that to the best of my knowledge the information in this evaluation form is true and correct. I understand that providing false or misleading information could result in Applicant s signature Reset Form 1. What type or types of disabilities prevent you from using the accessible fixed-route city bus service Check all that apply. General Medical Condition None Cancer Treatment Diabetes Dialysis Other describe Bone and Joint Condition Arthritis Osteoporosis Amputation of Broken bones specify Brain/Nerves/Muscle Condition Alzheimer s Disease Brain Injury Cerebral Palsy Confusion Dementia Epilepsy Multiple Sclerosis Paraplegia Parkinson s Disease Post-polio Quadriplegia Stroke Heart and Circulatory Condition Edema Heart Disease Lung and Breathing Condition Asthma Chronic Obstructive Pulmonary Disease Emphysema Lung Cancer Vision/Hearing/Speech Condition Deaf Deaf-Blind Glaucoma Hard of Hearing Legally Blind Night Blindness Non-Verbal Developmental or Mental Condition Developmental Disability Mild Moderate Severe Mental Retardation Autism Downs Syndrome Mood Disorder Psychosis Please describe your medical condition/disability in more detail 2. Is the medical condition/disability temporary or permanent permanent temporary I expect it to last I don t know 3. Does your health condition/disability change from time to time in ways which affect your ability to use an accessible fixed-route city bus no yes describe cane crutches leg braces walker alphabet/picture board portable oxygen power scooter/cart power wheelchair manual wheelchair service animal 5. Do you require the assistance of a Personal Care Attendant PCA someone who assists you with daily life functions when traveling within the City yes 6. Have you ever used the accessible fixed-route city bus service yes I use the accessible fixed-route city bus service about times a week yes I did in the past but have stopped because 7. Is there something that might help you to ride the accessible fixed-route city buses Check all that apply.

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