Roseville Transit ADA Paratransit Service Eligibility Application

All information you supply is confidential and will only be used to determine if you are eligible for Roseville Transit's ADA Paratransit Service.

ADA Paratransit cards are free to obtain. 

316 Vernon St., Suite 150
Roseville, CA 95678
Monday - Friday, 8 a.m. - noon and 1 - 4:45 p.m.
(916) 774-5293
Email Us

Part A: Applicant Information
Date of Birth:
Last Name:
First Name:
Mailing Address:
City:
State:
Zip Code:
Email:
Notifications:

Yes, I'd like to receive occassional emails with important information about bus services and schedule changes.
Your email is never shared or sold, and you may unsubscribe and manage your subscription at any time. 

Yes

No

Daytime Phone Number:
Alternate Phone Number:
  
Part B: Emergency Contact Information
Name: 
Relationship:
Home Phone Number:
Work Phone Number:
Cell Number:
  

Part C: Mobility Information

Do you normally use any of the following mobility aids?

Manual wheelchair
Electric wheelchair
Powered scooter(3 or 4 wheels)
Walker
Cane
Service Animal
None
Do you need a personal care attendant (PCA) to assist you to board, ride, or disembark from an accessible Local bus? The bus driver cannot act in the role of a PCA. 
No
Yes

Sometimes

 

Please explain when a personal care attendant is needed:

  
Part D: Functional Information
What is your disability or health-related condition that prevents you from using a regular Local bus? Describe all physical, sensory, and/or mental limitations in detail. Do not use acronyms. 
Are your disibilities... 
Permanent

Temporary

From:  

At a bus stop served by more than one bus route, can you distinguish the correct bus to board and indicate intention to board?
Yes
No
Sometimes
 

Please explain:

Are you able to board and disembark from a Local bus with a wheelchair/passenger lift without assistance (except from the bus driver)?
Yes
No

Sometimes

Please explain:

Are you able to handle/grasp coins (pay fare), tickets or passes, railings, and handles?
Yes
No

Sometimes

Please explain:

Are you able to keep your balance while seated on a moving Local bus in normal operation?
Yes
No

Sometimes

Please explain:

Are you able to read, hear, and/or understand the information, schedules, or directions during a trip?
Yes
No

Sometimes

Please explain:

Are you able to signal the bus driver that you want to disembark at a certain bus stop? (Assume the driver announces all major stops)
Yes
No

Sometimes

Please explain:

 

Are you able to find your way between familiar locations?
Yes
No

Sometimes

Please explain:

Are you prevented from travling to or from a bus stop due to extreme sensitivity to heat?
Yes
No
Are you prevented from traveling to or from a bus stop due to allergic or environmental sensitivities?
Yes
No
Are you prevented from traveling to or from a bus stop due to hyper-fatigue or frailty?
Yes
No
Are you prevented from traveling to or from a bus stop due to night blindness?
Yes
No

Are you prevented from traveling to or from a bus stop for any other reason? Please explain:

Are you able to wait outside at the bus stop without assistance or support for up to 15 minutes?
Yes
No

Sometimes

Please explain:

 

Part E: Applicant Signature

I hereby certify that the information given in this application is correct.

Name:
Date:
  
Part F: Person other than applicant completing form
Name:
Date:
Address:
Phone: 
Relationship to Applicant:
  

Part G: Authorization to release personal information

I hereby authorize the release of information to the City of Roseville Department of Public Works about my functional travel abilities. The information released wil be used solely to determine my eligibility for Roseville Transit's ADA Paratransit Service. 

Name of Professional*:

* Professional is an individual knowledgable of your disibility or disabilities and functional travel abilities such as rehabilitation specialist, disability evaluator, mental health case worker, or physician
Agency/Organization:
Phone Number:
I realize that I have the right to receive a copy of this authorization and that I may revoke this authorization at any time.
Name of applicant:
Date submitted:
Signature of applicant:

 

 



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