Application for ADA Eligibility Certification Program FacebookThis field is for validation purposes and should be left unchanged.Are you a new applicant or are you re-certifying? New Applicant Recertifiication If recertification, please include current ADA ID NumberName First Middle Last 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 PhoneAlternate Phone NumberDate of Birth (mm/dd/yyyy)Please enter your date of birth as month / day / year.Lanugage PreferenceGenderEmail Address Emergency Contact InfoFull Name First Middle Last Phone NumberAlternate Phone NumberPlease note: ADA certification is not a guarantee that origin to destination services will be available in your service area. Please check with your local paratransit operator to ensure which areas are covered. At the discretion of the paratransit company, limitations may also apply where the paratransit vehicle is unable to safely navigate to/from a specific location. The following terms may be used during the application process and are defined as follows Personal Care Attendant (PCA) – The Americans with Disabilities Act (ADA) defines a PCA as someone designated or employed specifically to help a person with their personal needs. If you have a family member, friend, or neighbor who helps you or if someone has been hired to help you with certain activities, they will qualify as a Personal Care Attendant. Public Fixed Route Bus – A bus that runs along a fixed route with a specific schedule of stops. Paratransit (Dial-A-Ride) – A transportation service which operates in response to calls from passengers to the local transit operator. Vehicles pick up passengers and transport them to their destinations. The vehicles do not operate over a fixed route or on a specific schedule. Section 1 – Accessibility1. Do you have a disability that prevents you from using a public bus? Yes No If yes, please explainSection 2 – Assessment2. Please review the list below and indicate which (if any) conditions apply to you. Difficulty breathing Nerve condition Seizure disorder Heart condition Mental health Intellectual Developmental Mobility Low vision Blind Require guidance to get on the bus Other vision condition – please explain Hard of hearing Deaf Other hearing condition – please explain Other vision condition – please explainOther hearing condtion – please explain3. When did the above condition(s) begin? 0 to 1 year ago 1 to 5 years ago Longer than 5 years ago 4. Is your disability considered… Temporary Stable Progressive Permanent 5. Does your disability change after medical treatments or medications? Yes No Sometimes If "yes" or "sometimes," please explain. Section 3 – Functional Ability6. Do you use any of the following Mobility Devices/Assistive Technology? Support cane White cane Collapsible walker (with or without seat) Walker with seat Manual wheelchair Reclining wheelchair Power chair Scooter Crutches Leg braces Charcot boot Portable oxygen device Hearing aid(s) 7. Do you use a communication device? Yes No If yes, what type of communication device do you use?8. Do you have a service animal? Yes No If yes, what type of service animal do you have?How does your service animal help you?Please note: If you need help in completing Questions 9 and 10 below, please call us at 888.667.7001 and we will help you.9. If you use a wheelchair or scooter, do you know about how much you and your wheelchair/scooter weigh together? Yes No If yes, please indicate the weight of yourself and your wheelchair or scooter. Less than 300 pounds 300 to 600 pounds More than 600 pounds 10. Do you know the dimensions of your wheelchair? Yes No If yes, please provide the dimensions of your wheelchair in inches.Wheelchair WidthWheelchair DepthWheelchair Height11. Please tell us which of the following you are able to do. (Please check all that apply) Go up and down 3 or 4 stairs Go up and down a hill Go up and down a curb Go across pavement that has raised bumps on it Cross a two lane street before the signal turns red Travel by yourself in the evening or early morning with limited light Travel to the nearest public bus stop in weather that is very hot Travel to the nearest public bus stop in weather that is very cold Stand at a public bus stop if there is no seating Wait at a public bus stop if there is no shade Go up or down a ramp Get on and off a public bus if it has a lif Grasp handles or railings when getting on and off of a public bus Keep your balance while seated on a moving vehicle Recognize street signs Read letters and numbers on street signs and buses Follow written instructions Follow oral instructions Read lips (if deaf) Handle coins or paper money Count change Tell time Section 4 – Public Transit ExperienceThe following questions are to help us understand if you are able to use the public fixed route bus system safely and independently. Whether or not you have used public transit recently or in the past will not prevent you from being eligible to apply for ADA paratransit services.12. Do you know the name of your local transit agency? Yes No If yes, please list the name of your local transit agency.13. Have you ever used the public fixed route bus, trolley, or trains? Yes No If yes, how long ago and how frequently did (do) you use these types of transportation?14. How close is the nearest public bus stop to your home? Less than 2 blocks Between 2 and 4 blocks More than 4 blocks I do not know 15. Are you able to travel to the nearest public bus stop independently? Yes No Sometimes If you cannot travel to the nearest public bus stop independently at all or sometimes, please explain why.16. Are there other reasons that are keeping you from reaching/using the public bus stop? Yes No Sometimes If there is anything keeping you from reaching or using the public bus stop, please explain.17. Do you travel with a Personal Care Attendant? Yes No Sometimes 18. Please add any additional information that you believe will help us determine your eligibility for ADA services.The following question is optional, applicant is not required to answer, and does not affect your eligibility for ADA.19. Would you allow us to share your information with emergency service agencies for the purpose of emergency planning? Yes No Release of Information Name First Middle Last The ADA Certification Coordinator will be contacting the provided licensed health professional below for verification of your disability and how your disability prevents you from using bus or rail service. All information will be confidential and will only be used to determine eligibility for ADA Paratransit service. The ADA Certification Coordinator will not release the information to any other person or agency without your permission. Information may be given to agencies to provide appropriate transportation access and accommodations. I authorize the licensed health professional listed below as well as their office staff to furnish information regarding my disability and functional capabilities that may help Ventura County Transportation Commission’s ADA Certification Coordinator evaluate my application for Paratransit / Dial-a-Ride services.Licensed Health Professional First Last ProfessionAddress 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 PhoneFax (REQUIRED)Confirmations I hereby certify that the information given here is complete and correct to the best of my knowledge. I understand that I may be required to attend an in-person interview and assessment before a determination of eligibility is made. I understand that if I am not found to be eligible for ADA paratransit service that I may appeal the determination within 60 days after receipt of written determination, and that I will be advised of the procedures of such an appeal. If this application is completed by someone other than the applicant, please provide details below:Representative Full Name First Middle Last Date (mm/dd/yyyy)*This person is not able to access information about this application unless also listed as a legal conservator.For questions please contact ADA Certification Coordinator at (888)-667-7001. Alternatively, you may complete a print version of this application and retern it via, mail, email, or fax. Ventura County Transportation Commission C/O Mobility Management Partners (MMP) ATTN: ADA Certification Coordinator 4036 Adolfo Road, Camarillo, CA 93012 Email: info@mobilitymp.org Fax: 1-888-667-7002 Please note: ADA certification does not guarantee origin-to-destination services in your area. Confirm covered areas with your local paratransit operator, as limitations may apply based on the company’s discretion and the vehicle’s ability to navigate safely to/from specific locations. If you require immediate paratransit services, please complete this application and submit it to the ADA Certification Coordinator before contacting your local public transit provider. If you are unsure of your local transportation provider, please call (888) 667-7001
