CLIENT APPLICATION FORM

Transcription

1 CLIENT APPLICATION FORM ACCESS-A-Ride Lethbridge Transit th Avenue North Lethbridge, AB T1H 0K4 Phone Fax AAR@lethbridge.ca ACCESS-A-Ride is a specialized Lethbridge Transit service for people who are prevented from using the fixed route transit service with safety and dignity due to a cognitive or functional disability. All persons must register for the specialized service and may be required to renew their registration on an annual basis. Any charges incurred for completing this form or for obtaining additional information are the responsibility of the applicant. The completion of the application form does not guarantee eligibility. All Lethbridge Transit fixed route buses are low floor and 100% accessible. If you need help learning to ride Transit, please call our office to arrange a training session. Applications must be completed in full and signed before they are considered for approval. Incomplete forms will be returned. You may be required to attend an interview or assessment as part of the application process. Once this application has been completed in its entirety, please , fax, mail or deliver it to: ACCESS-A-Ride Lethbridge Transit Avenue North Lethbridge, AB T1H 0K4 Phone: (403) Fax: (403) AAR@lethbridge.ca If your transportation is to be paid for by a program or a 3 rd party, please also attach our Billing Request Form. If you will require ACCESS-A-Ride to travel from the same origin to the same destination at the same time of day on a regular bases for an extended period of time, you may qualify for a subscription trip. You may include an application for a subscription trip with this application. All forms are located on our website at or they can be picked up at our office. If you have any questions about this application, please feel free to visit us online or call our office. Please note that if your application is approved and you do not use ACCESS-A-Ride for a period of 12 consecutive months, you registration will become invalid and you will have to reapply for the service. Please remember to make a photocopy of this completed application for your records. APPLICATION INFORMATION Page 1 of 5

2 SECTION A: Client Information (MUST BE COMPLETED IN FULL) Last First Middle Street Address of Residence: Apartment/Room # Lethbridge, AB Postal Code: Male Female Date of Birth: Month / Day / Year Pick Up Address: Front Back Side Basement SECTION B: Mailing Address (IF DIFFERENT FROM SECTION A) City: Province: Postal Code: SECTION C: Billing Address (IF DIFFERENT FROM SECTION A) City: Province: Postal Code: SECTION D: Emergency Contacts (PLEASE LIST 2 MUST BE COMPLETED IN FULL) SECTION E: Client Questionnaire (MUST BE COMPLETED IN FULL) What mobility aids do you use when travelling in the community? Please check all that apply. Your answers will ensure the appropriate specialized service will be provided. None Cane Walker non collapsible Manual Wheelchair** Scooter** Oxygen Walker - Collapsible Electric Wheelchair** Service Animal Other: SELF ASSESSMENT Page 2 of 5

3 **Please Note: If a wheelchair or scooter is used, the maximum base dimensions are 30 x 50 (76x127 cm). Equipment larger than this cannot be accommodated. A combined weight of the equipment and the passenger cannot exceed 750lbs (340 kg). Does the outside dimensions of the wheelchair/scooter exceed these measurements? Yes No Does the combined weight of the passenger and mobility device exceed this weight? Yes No If yes to either, please explain: Please describe how your condition affects your ability to use Lethbridge Transit fixed route service. Would you be able to use Lethbridge Transit fixed route service if you were taught how to use the system? Yes No If no, please explain: _ Can you recognize landmarks? Yes No If no, please explain: Will you require a mandatory attendant when using ACCESS-A-Ride? Yes No Can you be left alone at your destination? Yes No If no, please explain: I HEREBY CERTIFY THAT I HAVE REVIEWED THE INFORMATION PROVIDED IN SECTION A THRU SECTION E AND CERTIFY IT TO BE TRUE. I GIVE PERMISSION FOR LETHBRIDGE TRANSIT ACCESS-A-RIDE TO CONTACT MY AUTHENTICATOR TO VERIFY THE NEED FOR MY REQUEST. Applicant Signature: Date: If someone else has completed this form on behalf of the applicant, please provide the following: Signature: Date: SELF ASSESSMENT Page 3 of 5

4 SECTION F: Authenticator Assessment - Health Care or Social Service Practitioner All applicants must complete Section F unless at least one of the following criteria is met. Are you (please check all that apply): Using a wheelchair or scooter on a permanent basis Enrolled in an Adult Day Program. Please list: A resident in an extended care facility. Please list: A registered member of CNIB. Please list your registration #: The purpose of this assessment is to provide sufficient information about the applicant to permit Lethbridge Transit ACCESS-A-Ride to assess the applicant s eligibility for services. ACCESS-A-Ride may request more information from the person completing this assessment. Any charges incurred for completing this application or for obtaining additional information are the responsibility of the applicant. The completion of this assessment does not guarantee eligibility. All parts of this assessment must be completely filled out and signed by a qualified health care or social services practitioner familiar with the applicant s disability (such as a registered nurse, occupational therapist, rehabilitation practitioner, case worker or family physician). Any forms that are unclear or incomplete will be returned to the applicant. Applicant Name of Authenticator: Position: Institution/Company: Phone #: Fax #: What are the conditions that prevent the applicant from using the regular fixed route transit system? Will the effects of the applicant s disability decrease or change over time (e.g., mobility after knee surgery will improve in a few months). Yes No If yes, please explain: It is my professional opinion that the applicant has a disability that (check ONE box that best explains the applicant): Prevents them from using Lethbridge Transit fixed route service in the winter only Prevents them from using Lethbridge Transit fixed route service Prevents them from using Lethbridge Transit fixed route service unless an attendant accompanies them Other (please explain): AUTHENTICATOR ASSESSMENT Page 4 of 5

5 If the applicant is approved for ACCESS-A-Ride specialized services, it is my professional opinion that they will require the service for: Less than 3 months. Please indicate length of time: 3 months 6 months 1 year 3 years or more Seasonal November 1 thru April 30 th each year Will the applicant require a mandatory attendant when using ACCESS-A-Ride? Yes No If yes, please explain: Can the applicant be left alone at his/her destination? Yes No If no, please explain: Can the applicant be left alone at home? Yes No If no, please explain: Did you complete an assessment to determine the applicant s functional ability to take transit? Yes No If yes, please explain and provide the date the assessment was completed: Could the applicant learn to use Lethbridge Transit fixed route service if someone taught him/her how to use it? Yes No If no, please explain: How long have you (or your agency) been involved in the assessment of the applicant s condition? I HEREBY CERTIFY THAT I HAVE REVIEWED THE INFORMATION PROVIDED IN SECTION F AND CERTIFY IT TO BE TRUE. I GIVE PERMISSION FOR LETHBRIDGE TRANSIT ACCESS-A-RIDE TO CONTACT ME OR MY OFFICE TO VERIFY THIS INFORMATION OR FOR ADDITIONAL INFORMATION. Signature of Authenticator: Date: AUTHENTICATOR ASSESSMENT Page 5 of 5