Tri Delta Transit Senior Paratransit Application Packet.

Transcription

1 Tri Delta Transit Senior Paratransit Application Packet. This packet contains the following: 1) Information about Senior Paratransit Service including service area maps (pages 1-4) 2) Senior Paratransit Application (pages 5-7) 1

2 Important Application Information for Senior (Age 65+) Paratransit Transportation You must be 65 years of age or older to receive Senior Paratransit transportation Senior Paratransit transportation is limited to Tri Delta Transit s service area in Eastern Contra Costa County (see attached map) Senior Paratransit transportation operates the following hours - Monday Friday 6:30 am to 5:30 pm - Saturday 10:00 am 5:30 pm - Sunday No service available All Rides are subject to availability and are not guaranteed. For help with the application process, call All information that you include on your application will be kept confidential. 2

3 PARATRANSIT AREA CONCORD BAY POINT East Contra Costa Clinic Pittsburg Senior Center Pittsburg Marina Municipal Court CLAYTON PITTSBURG Atlantic Plaza DMV County Social Services Century Plaza Social Security Office ANTIOCH 4 4 Pittsburg Golf Club Pittsburg/Bay Point BART Station Pittsburg Health Center Kaiser Medical Clinic Somersville Towne Center Sutter Delta Medical Center Antioch Marina Amtrak Station City Hall County Fair Grounds Community Center Kaiser Permanente Antioch Prewett Family Water Park 160 OAKLEY Streets of Brentwood Slatten Ranch Shopping Center Big Break Marina 4 BRENTWOOD City Hall 10th Main St N Parkside Dr W 10th E 14th Willow Pass Rd ADA Service Area A St L St Neroly Rd Buchanan Rd Loveridge Rd Railroad Ave Main St Highway 4 Bypass Hillcr est Ave Contra Loma California Delta Hwy Tree Way Lone Fairview Ave Balfour Rd City Hall WEEKDAY 3

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5 Senior Paratransit Application (Please Print or Type) Name (first, middle, last): Home Address: Apt. #: City: Zip: Mailing Address (if different from home): Apt. #: City: Zip: Cell Phone: ( ) TDD/TTY: ( ) Home Phone: ( ) Birth Date: / / c Female c Male Primary Language (please check): c English c Other (specify) If you need any future written information provided to you in an accessible format, please check which format you prefer: c Diskette/CDR c Audio tape c Braille c Large Print c Other In case of emergency, whom should we contact? Name: Relationship: Cell Phone: ( ) Home. Phone: ( ) If there is a medical emergency, where do you want to be transported? Hospital: City: 5

6 Applicant Certification I certify that the information in this application is true and correct. I understand that knowingly falsifying the information will result in denial of service. I understand all information will be kept confidential, and only the information required to provide the services I request will be disclosed to those who perform the services. Sign here: Applicant s signature Did someone help you in filling out this form? c Yes c No If yes, Name: Phone: ( ) Relationship: Do you use any of the following mobility aids or specialized equipment? (Check all that apply): c Cane c Power Wheelchair c Communication Devices c White Cane c Service Animal c Walker c Power Scooter c Crutches c Manual Wheelchair c Leg Braces c Portable Oxygen Tank c Other Aid 6

7 Paratransit Rider Responsibility Tri Delta Transit is committed to providing safe, secure, and reliable service to our customers. To ensure this level of service, the cooperation and support of our customers is critical. It is for this reason that the following rules have been adopted. I, understand that is it my sole responsibility, or that of my Power of Attorney or Conservator to contact Tri Delta Transit with any of the following changes during the course of my registration with Tri Delta Transit s paratransit service: My name, address and/or telephone number Emergency contact s name and/or phone number Type of mobility device Change(s) to physical or mental condition Need for a personal care attendant Signature Date Please note: All three pages of this application must remain attached. If the application is received without all three pages, it will be considered incomplete. 7