Petersburg Area Transit: ADA PARATRANSIT ELIGIBILITY APPLICATION
Paratransit Service is a specialized transportation service for persons with disabilities, seniors with disabilities, handicapped and who are unable to independently use PAT fixed routes.
Paratransit is provided by public transportation systems as part of the requirements of the
Americans with Disabilities Act (ADA).
In order to use ADA Paratransit service, you must first be certified as eligible. Please read the following instructions before filling out the attached application form. All information that you supply will be kept
strictly confidential.
1. Please FULLY answer all questions on the form and return it to the transit system
(Incomplete applications will not be processed and will be returned to you for completion)
2. Your application will be reviewed, and an eligibility determination will be made within 21 days of
receiving a COMPLETE application. Presumptive eligibility is granted on the 22nd day until and
unless the application is denied in writing. You will receive a letter as to whether/or not you are eligible.
3. Eligible for all your travel needs on Paratransit may be full eligibility or conditional eligibility depending
on the nature of your disability or circumstances.
4. Petersburg Area Transit, Paratransit, reserves the right to make the final determination as to an
applicant’s eligibility.
NOTE: “Use of a wheelchair does not imply automatic eligibility, for example, since many individuals
who use wheelchairs are able to use fixed route services for many or all of their trips.
Nor is ADA paratransit eligibility based on age, income, or whether or not individuals can drive or have
access to private automobile transportation.”
Thank you!
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Petersburg Area Transit: ADA PARATRANSIT ELIGIBILITY APPLICATION
If you have a disability that prohibits you from riding our standard Petersburg Area Transit fixed route bus system, you may be eligible to receive Paratransit Services. Paratransit Services is an ADA (Americans with Disabilities) door-to-door bus service.
This means transportation will take you from the pickup location to your drop off location.
This application will be used to determine the extent of your disability as it relates to being able to utilize our
standard public transit fixed route system
A few items to remember as you read, understand, and complete this application:
1. A friend or relative may fill out the application on your behalf. If someone fills out the application for you,
they must also complete Part D of the application.
2. It is important that you answer every question on the application. Give as much detail as possible.
We understand that some of your answers may be personal. Any information received is confidential
and will not be provided to any other agent that is not directly related to this certification process.
3. Evaluation of your request cannot begin until we have received the completed form.
This must include Part E signed, Authorization to Release Personal Information.
a. Upon approval you may go to the Petersburg Transit Station at 100 West Washington St.,
on the second Tuesday of every month from 9am until 12pm and receive and A photo
identification card.
o Note: Riders are currently not using ID cards. PAT will notify riders when we resume
issuing AD photo ID cards.
Please remember: • Drivers can offer stabilization assistance when a passenger is loading and unloading
the vehicle, when securing a mobility device and at seat belt securement. • Drivers are not trained to act
as Personal Care Assistants (PCA). Please indicate on your Paratransit application if you require and will
have a PCA (Personal Care Assistant) or a companion rider with you. A PCA with an employer issued ID
will be allowed to travel for FREE.
A companion rider must pay the same fare as the applicant. After all sections below are filled out by the
applicable person(s), mail the finished application to:
Petersburg Area Transit ATTN:
Paratransit Supervisor 100 W Washington St
Petersburg, VA 23803
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Petersburg Area Transit: ADA PARATRANSIT ELIGIBILITY APPLICATION
Español
El servicio de paratránsito es un servicio de transporte especializado para personas con discapacidades,
personas mayores con discapacidades, discapacitados y que no pueden utilizar de forma independiente
las rutas fijas de PAT.
Los sistemas de transporte público proporcionan paratránsito como parte de los requisitos de la Ley de Estadounidenses con Discapacidades (ADA, por sus siglas en inglés). Para utilizar el servicio de
paratránsito de la ADA, primero debe estar certificado como elegible.
Por favor, lea las siguientes instrucciones antes de rellenar el formulario de solicitud adjunto.
Toda la información que proporcione se mantendrá estrictamente confidencial.
1. Responda COMPLETAMENTE todas las preguntas en el formulario y devuélvalo al sistema de tránsito
(las solicitudes incompletas no se procesarán y se le devolverán para que las complete)
2. Su solicitud será revisada y se tomará una determinación de elegibilidad dentro de los 21 días
posteriores a la recepción de una solicitud COMPLETA. La elegibilidad presunta se otorga el día 22 hasta
que la solicitud sea denegada por escrito. Recibirá una carta en la que se le indicará si es elegible o no.
3. Elegible para todas sus necesidades de viaje en Paratransit puede ser elegibilidad completa o elegibilidad condicional dependiendo de la naturaleza de su discapacidad o circunstancias.
4. Petersburg Area Transit, Paratransit, se reserva el derecho de tomar la determinación final en cuanto a la elegibilidad de un solicitante. NOTA: "El uso de una silla de ruedas no implica la elegibilidad automática, por ejemplo, ya que muchas personas que usan sillas de ruedas pueden usar los servicios de ruta fija para muchos o todos sus viajes.
Tampoco la elegibilidad para el paratránsito de la ADA se basa en la edad, los ingresos o si las personas pueden o no conducir o tener acceso al transporte privado en automóvil".
¡Gracias!
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Petersburg Area Transit: ADA PARATRANSIT ELIGIBILITY APPLICATION
___ New Application ___Recertification
Please write clearly. All questions MUST be answered.
PART A: APPLICATION DATA
1. Name______________________________ Birth Date ____/_____/______
2. Social Last 4: 000-00- _______
a. Male ________ Female _________
3. Street Address_________________________________________________________
City: ______________________________________ Zip________________________
4. Home Telephone: (_____) ______________ Work Telephone: (_____) _____________
5. Emergency Contact Person _________________ Phone Number (_____) _______________
6. Indicate race status below:
____White or Caucasian Only ____ Black / African American Only ____ Hispanic / Spanish
Only
____ Native Hawaiian or Pacific Islander Only _____ Asian Only
____ Two or More Races Combined ____ Race Unknown or Unreported
7. Do you normally use any of the following mobility aids? Yes_______ No________
____ Manual Wheelchair _____ Electric Wheelchair ______ Powered Scooter (3 or 4 wheels)
____ Walking Cane _____ White Cane (visually impaired) _____ Crutches _____ Walker
____Service Animal _____ Portable Oxygen _______ Other: _______________________
Do you have a handicap ramp that meets Commonwealth of Virginia “Uniform State-Wide
Building code" for wheelchair ramps? Yes _______ No_______
Total Weight of Person + Mobility Aid / Wheelchair __________lbs. (cannot exceed 800 lbs. total)
8. Do you require a personal care assistant that you will provide (someone other than the
operator of the passenger lift) to assist you to board, ride or disembark from an accessible
Paratransit vehicle? Yes ______ No_______ Sometimes_______
8a. Please explain when an attendant is needed:
______________________________________________________________________________________
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Petersburg Area Transit: ADA PARATRANSIT ELIGIBILITY APPLICATION
9. Can you read informational signs? Yes _______ No ___________
10.Can you deal with unexpected situations or changes in routine?
Yes _________ No _________
11. When you travel can you move around by yourself? Yes ____________ No _________
12. Can you ask for, understand, and follow directions? Yes _____________ No _________
13. If you cannot climb the steps, can you hold onto the handrails and ride lift up into the
bus on a wheelchair on the buses that are equipped to do so?
Yes __________ No ____________
14. What weather conditions, if any, affect your ability to ride a regular fixed route bus?
______________________________________________________________________
15. All Paratransit rides are currently fare FREE until further notice. Rides were $1.75 per
one way trip prior to the announcement of fare FREE services. You will be notified if,
and when, fare prices go back into effect.
16. To obtain an ADA Paratransit identification card, you must show proof of your age by
submitting a copy of one of the following:
o Baptismal Certificate
o Birth Certificate
o Driver’s License / State Issued ID Card
o Other (Military ID, Voter Registration Card, etc.)
- - - - - - - - - -OFFICE USE ONLY- - - - - - - - - -
Approval Date: _________________________ Attendant: ______________________
Denial Date: ___________________________ Photo I.D. Date: _________________
Denied By: ____________________________ Expiration: ______________________
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Petersburg Area Transit: ADA PARATRANSIT ELIGIBILITY APPLICATION
Please write clearly. All questions MUST be answered.
PART B: FUNCTIONAL INFORMATION
1. Describe your physical, sensory and/or mental limitation that prevents you from using the
regular fixed-route bus services.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. Are your disabilities: ______ Permanent ______ Temporary ____ Variable Until ___________
3. What is the maximum time period you can wait without support? _______Minutes
Is this time period affected by extremes of hot or cold weather? Yes ________ No___________
If yes, please describe your situation below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PART C: APPLICANT SIGNATURE
I hereby certify the information given in this application is correct:
Signature: __________________________________ Date: ________________
PART D: PERSON OTHER THAN APPLICAT COMPLETING FORM
Printed Name: _______________________________________________________________
Address: ____________________________________________________________________
Phone Number: ______________________________________________________________
Relationship to Applicant: ______________________________________________________
Sign: ________________________________________________ Date: ____________
(Signature of Person Completing Form for Applicant)
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Petersburg Area Transit: ADA PARATRANSIT ELIGIBILITY APPLICATION
PART E: AUTHORIZATION OF PROFESSIONAL TO RELEASE PERSONAL INFORMATION
Incomplete forms will not be considered. A physician must verify your disability, prognosis, and date of
occurrence. Verification can be obtained directly from your physician or an agency that has a record of
the physician statement on file. This information must be submitted with the application and written on
the physicians' official letterhead or on the Physician Verification or Disability Form. The information you
provide is confidential. It will not be shared with any other organization except as allowed by the
Virginia Freedom of Information Act.
Verification of Information: I verify that all statements are true and correct to the best of my
knowledge. I understand that supplying false information can disqualify my application and/or
I understand that supplying false information can disqualify my application and/or
subsequent registration. I authorize Petersburg Area Transit to obtain verification of any information
given in this application and to obtain essential medical information necessary for determination of
Paratransit eligibility. I also agree to submit myself an in-person evaluation by PAT and/or its acting agent
for determination of Paratransit eligibility.
I also certify that to be transported, my mobility device may not exceed a maximum of 800 lbs.
total weight when occupied and fit into a designated space. (Ex: body weight + chair weight
cannot exceed 800 lbs. total.
I hereby authorize the limited release of information to the PAT about my functional travel abilities.
The information released will be used solely to determine my eligibility for ADA Paratransit Services.
Name of Professional:___________________________________________________________________
Agency/Organization:___________________________________________________________________
Phone Number: _______________________________________________________________________
Authorized Signature:___________________________________________________________________
I realize that I have the right to receive a copy of this authorization. I understand that I may revoke this
authorization at any time. Name of Applicant
(Print Please) _____________________________ Date _____________________
Signature of Applicant __________________________________________________________________
Note: Verifying "Professional" may be a rehabilitation specialist, disability evaluator, mental health case worker,
physician or other such individual knowledge of your disability or disabilities and functional travel abilities.
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Petersburg Area Transit: ADA PARATRANSIT ELIGIBILITY APPLICATION
Physician Verification of Disability Form - Under the Americans with Disabilities Act of 1990 (ADA)
(Deliver or Mail THIS PAGE to your Doctor for completion)
Doctor: Please complete, sign, and mail this Verification of Disability form as soon as possible.)
Your patient is being considered. For enrollment in Petersburg Area Transit Paratransit service.
The information provided in this form is intended to verify any conditions/diseases that prevent your patient,
NAME of Patient, ________________________________ from using standard public
Petersburg Area Transit / fixed-route services.
Mail to Petersburg Area Transit,
Attn: Paratransit Supervisor, 100 W. Washington St., Peterburg. VA 23803
or Fax to: 804-733-2468.
Does the patient use mobility aids? Yes ______
Explain: ________________________________ No_________
If using mobility aid, how far can the patient travel without help (one block = approx. 500ft.)? ________
blocks
Patient DOB ______________/_____________/_____________
Name of condition/disease: _______________________ Date of onset: _________________________
Prognosis: _________________________________________________________________________
Will the patient require any assistance while traveling on our vehicle? _______________________________________________
Does this patient have a HEARING IMPAIRMENT? _____ Yes _____ No
Please explain: _____________________________________________________________________
In your professional opinion does this person’s disability prevent him / her from getting to or from, boarding,
riding, or disembarking a regular bus Fixed Route Service? _______ Yes ________ No
Please explain what prevents your patient from using regular bus service on a fully accessible vehicle
(i.e., wheelchair lift equipped, holding rails):
_____________________________________________________________________________________
_____________________________________________________________________________________
Does the patient require a travel aid or attendant? ____ Yes ____No
***Continue to NEXT PAGE……
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Petersburg Area Transit: ADA PARATRANSIT ELIGIBILITY APPLICATION
Disability Status (select one): ____
Patient will be temporarily disabled.
Expected duration, please specify date range: _______ to __________ ______
Patient is considered permanently disabled. ____
Patient is not disabled. FOR VISUAL IMPAIRMENT _____ Right Eye _____ Left Eye
Please specify visual impairment:
_____________________________________________________________________________
My signature below certifies that the above information is accurate
(**Must be signed by a licensed physician**)
________________________________ __________________
Signature of Physician and Credentials (M.D., O.D.) Date
Physicians’ Office Phone Number: ( ) ____________________
License Number: __________________________________
State:___________________________________________
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