Greeley Evans Transit: Request for Certification of ADA Paratransit Eligibility "*" indicates required fields Step 1 of 9 11% Your application requires a signed release form. Would you like to complete this form electronically? Yes, I will complete it electronically at the end of this form No, I prefer complete a paper form and upload it Please upload your signed Release Authorization * RequiredPlease download our paper form, print and sign, and then upload your release. Accepted file types: pdf, Max. file size: 5 MB.Maximum file size - 5 mega bytes. Name * Required Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Email * Required Enter Email Confirm Email Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (Home) * RequiredPhone (Work)Phone (Cell)Date of Birth * Required MM slash DD slash YYYY What method of communication works best for you to receive notifications? * Required Home Phone Cell Phone E-Mail What is the disability that prevents you from using GET Fixed Route Services? * Required Cognitive/Developmental Visual Impairment/Blindness Physical Mental Illness Other Please provide brief description * RequiredPlease describe your disability in detail. Include how it prevents you from using fixed route services * RequiredThe above disability is * Required Permanent Temporary Unknown at this time Expected End of Temporary Disability * Required MM slash DD slash YYYY 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 requests can be made by Greeley-Evans Transit.Do you use any of the following aids for mobility? Check all that apply Cane Walker Crutches Portable Oxygen Larger Than Shoulder Bag Powered Scooter Powered Wheel Chair Manual Wheelchair Service Animal Other Mobility Device Note: GET may not be able to accommodate your mobility device if it exceeds 48 inches in length, 30 inches in width, or if the combined weight of the person and mobility device exceeds 600 pounds. Operators do not assist riders with connecting or disconnecting oxygen or other breathing aides. Operators do not lift and/or carry a passenger.What is the weight of your wheelchair or scooter with you in it? * RequiredBe sure to give use the total weight. That is the weight of yourself added to the weight of the chair.Width of Chair (inches) * RequiredHeight of Chair (inches) * RequiredLength of Chair (inches) * RequiredService Animal Type * RequiredService Animal Note: Service animals may not occupy a seat and must be under the direct control of the rider, guest, or PCA at all times.Other Mobility Device/Aid (Please Describe) * RequiredDo you require a Personal Care Attendant when you travel using transit? * Required Yes No PCA Note: GET does not provide PCAs and cannot assist you with functions such as taking medications, connecting/disconnecting medical equipment, eating, mobility beyond getting to/from the vehicle, personal hygiene, etc. GET staff are not authorized to enter any residence or any commercial building beyond a foyer or medical facility front waiting area. If you require assistance with these types of activities, we strongly suggest that a PCA accompany you.On your own, or with the use of an assistive device, how far can you travel? * Required I can get to the curb in front of my house/complex Up to ¼ mile (3 blocks) Up to ½ mile (6 blocks) Up to ¾ mile (9 blocks) or more Cannot travel outside of home Please explain 'cannot travel outside of home' * RequiredCan you climb three 12-inch steps without assistance other than installed handrails? * Required Yes No, I must use a wheelchair lift or ramp. Are you able to wait outside at a stop or pick up location for 10 minutes? * Required Yes Yes, if there is a bench or shelter Sometimes, weather permitting No Do you currently use regular fixed-route transit bus service for transportation? (This question does not automatically disqualify you from ADA Paratransit Service). * Required Yes No Sometimes What best describes how you use the fixed route service: * Required Travel to and from one destination only. Travel to and from few destinations. Travel to and from many destinations. Travel to locations that I am familiar. Someone must accompany or assist me when riding fixed route. Only if the weather is too hot or cold. Please check one answer to each question below according to how it relates to your ability to travel within the community and utilize GET transit buses * RequiredYesNoSometimesAre you able to tolerate very hot or very cold weather?Are you able to recognize destinations, landmarks, and bus stops?Are you able to recognize, read, and understand printed information?Are you able to communicate your needs to another personAre you able to follow directions?Are you able to hear and process spoken words or auditory information?Are you able to deal with unexpected situations or changes in routine such as bus detours?Are you able to recognize curbs and other drop offs?Are you able to travel independently along sidewalks and other pedestrian ways? Take into consideration any mobility device(s) you normally use.Are you able to cross streets independently?Are you able to identify the correct bus and/or bus stop?Are you familiar with what to do if you miss your expected bus?If you answered any of the above statements with “No” or “Sometimes”, please explain why Are there any other conditions that limit your ability to use GET buses?Any other information you would like to let GET know about your disability, expectations in travelling on GET system, or feedback on the service as you have experienced to this point. Contact PersonsPlease provide names and telephone numbers of up to three people that we may contact if the need arises.NamePhoneNamePhoneNamePhone Applicant’s CertificationPlease read and check the box next to each of the following statements, indicating you have read and understand them.Greeley Evans Transit is public transportation and I may be sharing rides with others. * Required I have read and understood this statementGreeley Evans Transit does not provide emergency services/emergency transportation. * Required I have read and understood this statementWhen I book a trip, the time I negotiate may be up to an hour before or after my desired time. * Required I have read and understood this statementGreeley Evans Transit may arrive up to 20 minutes after the scheduled pick up time to be considered on time. I will be ready and waiting for my ride at the scheduled pick up time. * Required I have read and understood this statementGreeley Evans Transit will only wait for 5 minutes after my scheduled pick up time, or bus arrival time, whichever is later, for me to board. * Required I have read and understood this statementI have received a pamphlet of general information about Greeley Evans Transit Paratransit Service. I may request a full copy of Greeley Evans Transit Paratransit Plan and Policies by contacting to the ADA Coordinator. * Required I have read and understood this statement ConfirmationIs this application being completed by someone other than the person requesting certification? * Required Yes No Person Assisting * Required First Last Address of Person Assisting * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone of Person Assisting * RequiredSignature of Person Assisting * RequiredSignature * RequiredBy signing you certify that that all information contained in this application is true and accurate. I understand that misinformation or misrepresentation of facts will be cause for disqualification or rejection of my ADA eligibility.Guardian Signature (If Applicant is Under 18 Years of AgePlease accept ride requests, cancellations, and other communications regarding the service from (please check all that apply): Myself (Applicant) Person Assisting in Completing the Application Person(s) indicated on my emergency contact list. Any other person(s) not named on this application (Please complete): Additional person (Please add name and phone number) * RequiredAdditional person (Please add name and phone number)Upon submission you will be redirected to the release form that must be completed along with your application. A copy of your entry will be sent to the email that you provided. If you have questions, please contact GET at 970-350-9290 or email [email protected].SignatureCAPTCHAFacebookThis field is for validation purposes and should be left unchanged.
