Application for CityLift Paratransit Services (Sunnyland Residents Only) - CityLink

Step 1 of 4

25%

Please note: At the end of this form, you must submit a statement from your physician on their prescription pad or official letterhead stating your disability or disabilities and in their professional opinion believe you are eligible for CityLift services. Your downloaded and completed medical professional section will need to be attached. If you have trouble viewing both pages of the document, please make sure to download the document instead of viewing in your browser.

Download Medical Professional Questionnaire

Rider Information

Name*

Prefix First Middle Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (daytime)*

Phone (evening)*

Date of Birth*

Month

Day

Year

Who do you reside with?*

In Case of Emergency Notify (List supported Living Contact, if applicable)

Emergency Contact Name

First Last

Emergency Contact Phone

Relation to applicant

Please answer the following questions:

Have you ever applied for a GP Transit, CityLink ADA Certification Card for Paratransit services before?

Yes

If yes, when? (date)

What disability prevents you from using the CityLink fixed route buses?*

Is your medical condition and/or disability temporary?*

Yes

Does your disability prevent you from getting to and from a bus stop?*

Yes

Using a mobility aid or on your own, how far can you travel without the assistance of another person?*

less than 3 blocks

3 blocks

6 blocks

9 blocks

Can you recognize your destination?*

Yes

Do you have difficulty receiving verbal or written directions?*

Yes

Is there a physical barrier combined with your disability that prevents travel to or from a bus stop? (example: stairs, no sidewalks, no curb cuts, heat, cold, ice, snow, etc.)*

Yes

Sometimes

If YES or SOMETIMES, please explain:*

Due to the limitations of my disability, I can wait outside at a fixed route bus stop only if:*

Check all that apply.

I can always wait outside at a bus stop.

There is a bench to rest on.

There is some sort of shelter from the weather.

The wait is no longer than…

The temperature is above…

The temperature is below…

I can never wait outside at a bus stop.

What is the maximum amount of minutes you can wait outside?*

What is the highest temperature you can wait outside?*

What is the lowest temperature you can wait outside?*

Why can you never wait outside at a bus stop?*

Due to the limitations of my disability, I can ride an accessible bus, (wheelchair lift equipped) operating on the fixed route only if:*

Check all that apply.

I can always ride on an accessible fixed-route bus.

I have an attendant with me (Personal Care Attendant)

I am familiar with the route.

I have received travel training.

A seat is available for me on the bus.

I can never ride on an accessible fixed-route bus.

Why can you never ride on an accessible fixed-route bus?*

Due to the limitations of my disability, I can recognize my destination and leave the bus only if:*

Check all that apply.

I can always recognize my destination and leave the bus.

I received travel training as to where my bus stop is.

The driver announces my stop for me.

I can never recognize my destination and leave the bus.

Why can you not recognize your destination and leave the bus?*

Which of the following mobility/communication aids do you use?*

Check all that apply.

Cane

Crutches

Powered Scooter/Cart

Communication Aide

Prosthesis

White Cane

Manual Wheelchair

Boarding Chair

Portable Oxygen

Walker

Powered Wheelchair

Service Animal

Transfer Board

None of These

If you use a Wheelchair or Scooter:

Is it more than 30 inches wide?*

Yes

Is it more than 48 inches long?*

Yes

Is the combined weight of the device and occupant more than 800 pounds?*

Yes

Are you able to travel independently or do you require a Personal Care Attendant (PCA) to assist you?*

No PCA

Full time PCA

Part-time PCA

Is there anything else about your disability and how it affects your ability to use public transportation? Please provide any information you feel would help:

Signatures

Signature of Applicant*

Signature of person other than applicant*

Medical Questionnaire & Physician Statement

Medical Professional Questionnaire & Physician Statement*

Please upload your Medical Professional Section and physician statement. Download Medical Professional Questionnaire

Please note: you must submit a statement

from your physician on their prescription pad or official letterhead stating your disability or disabilities and in their professional opinion believe you are eligible for CityLift services. Your downloaded and completed medical professional section will need to be attached. If you have trouble viewing both pages of the document, please make sure to download the document instead of viewing in your browser.

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 50 MB.

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.