Dial-A-RideNew Passenger Application Passenger Recertification Application Rider’s Guide Purchase Ride Tickets Online Rider Tips ADA Paratransit Recertification Application Step 1 of 5 - Instructions 20% Application for Recertification All information will remain confidential. In order to maintain your ADA Paratransit services all questions on this application must be answered in full. Failing to return a completed application will result in the delay of your transportation services. Either you or someone familiar with your condition may complete this form. If further documentation is needed to make an evaluation, you will be contacted by the Eligibility Intake Coordinator. Once the application is complete, please return it to: Easy Lift Transportation 53 Cass Place, Suite D Santa Barbara, CA 93117 If you have any questions about this application, please call our Eligibility Intake Coordinator at (805)845-8963. Name* First Last Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Address* 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 Complex If this is a "Gated Community", please provide gate code: Mailing address if different: 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 Email Day Phone #*Cell Phone #Best Way to Contact You* Please only contact me via email Please only contact me via snail mail I do not wish to receive follow up emails How did you hear about Easy Lift?*Emergency ContactPlease provide the name of a local friend or relative to call in case of emergency.Name* First Last Relationship* Email Day Phone #*Cell Phone # Section 1 - ContinuedALL INFORMATION IS CONFIDENTIAL AND WILL NOT BE DISCLOSED TO OTHERS. Questions 1, 2 & 3 are requested by our funding sources and do not determine your eligibility for Easy Lift's ADA2 paratransit services.How would you like written material sent to you in the future?* Large Print Audio Tape Braille Spanish Email What is the health condition or disability which prevents you from using the regular bus service?*Please answer the in detail - your specific answers to this question will help us in determining your eligibility. Is your condition...* Temporary Permanent If temporary, how long would you need our services*Will the passenger be responsible for reserving their own rides?"* Yes No If no, please state name and phone number of the person who will be making reservation for the passenger.Do you ever need to bring someone with you to help you when you travel? IE. A personal care assistant, an aide* Yes, always Yes, sometimes No If yes, please explain.Are you able to travel alone and be left unattended?* Yes, always Yes, sometimes No Which one of the following mobility aids, if any, do you use?* Crutches Cane Walker Power Wheelchair Power Scooter Manual Wheelchair High back Wheelchair Service/Guide Animal Portable Oxygen Other None If other, please explain.* Are you and your wheelchair a combined weight of over 600lbs?** Yes No *Please Note: A wheelchair or other mobility device must be able to fit onto our bus/paratransit lift. It is recommended that your wheelchair is no more than 30” wide and 48” long when measured 2” from the floor, and weigh less than 600 pounds, when occupied. If this is not the case, we will only be able to transport you if our equipment is able to withhold the dimensions of your mobility device. Section 2 - Information About Your Functional AbilitiesPlease answer the following questions in detail - your specific answers to the questions will help us in determining your eligibility. All answers requiring explanation must be complete.WITHOUT the help of someone else, can you...1. Ask for and understand written or spoken instructions?*AlwaysSometimesNeverNot Sure2. Cross the street?*AlwaysSometimesNeverNot Sure3. Stand for 15 minutes if there is no place to sit?*AlwaysSometimesNeverNot Sure4. Step on and off a sidewalk from a curb?*AlwaysSometimesNeverNot Sure5. Find your own way to the bus stop if someone shows you the way once or twice?*AlwaysSometimesNeverNot Sure6. Walk up and down three steps if there is a handrail?*AlwaysSometimesNeverNot Sure7. Walk up and down a flight of stairs if there is a handrail?*AlwaysSometimesNeverNot Sure8. Stand on a moving bus holding onto a handrail?*AlwaysSometimesNeverNot Sure9. Transfer from one fixed route bus to another?*AlwaysSometimesNeverNot Sure10. Are there any walls barriers or obstacles that block your path to the nearest bus stop?*AlwaysSometimesNeverNot Sure11. Under the best of conditions, what is the FURTHEST you can walk outdoors (or travel using your mobility aid) without the help of another person?* Less than 1 block 1 block 2 blocks (1/4 mile) 4 blocks (1/2 mile) 6 blocks (3/4 mile) More than 6 blocks I cannot travel outdoors alone at all 12. Is there anything else you want to tell us about your disability or health condition that might help us better understand your travel abilities and limitations? Section 3 - Certification of Applicant I hereby certify that, to the best of my knowledge, information given in this application is correct. I understand that this application will not be processed if it is not complete. I understand that the results of the review will be based on my ability to use regular bus transport and may require additional information from me, such as a phone or personal interview or additional consultation with my physician or other professional. I agree to notify Easy Lift Transportation, Inc. if I no longer need to use the ADA Paratransit Service. I further understand that my ADA Paratransit Eligibility Approval may be reassessed or revoked at any time, if eligibility was granted based on information which is found to be inaccurate, false, or which has changed significantly enough to warrant a change in category. Electronic Signature of Applicant* Date*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If someone other than the applicant completed this application, their information must be provided.Name of person completing or assisting with the application Relationship to Applicant Signature of Assistant DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Daytime PhoneEvening Phone
