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2. Americans with Disabilities Act (ADA) Paratransit Eligibility Standards:
4. • Any individual with a disability who is unable, as a result of a physical or mental impairment (including vision impairment), and without the assistance of another individual (except the operator of a wheelchair lift or other boarding assistance device), to board, ride, or disembark from any vehicle on the system which is readily accessible to and usable by individuals with disabilities.
6. • Any individual with a disability who has a specific impairment-related condition which prevents such individual from traveling to a boarding location or from a disembarking location on such system.
8. After reviewing the above information, if you feel that your disability may fit into one of the above mentioned categories, please complete the Paratransit Application in full.
10. If you do not meet the above criteria, have questions or comments about paratransit service, or need this application in an accessible format, please contact Customer Service at 434-970-3649 (Option 2).
12. First Name
13. Last Name
15. Date of Birth
17. Street Address
19. City
20. State
21. Zip Code
23. Telephone
24. Other Telephone
26. Emergency Contact Person
28. Emergency Contact Phone Number
30. Do you use any of these mobility aids?

    Check all that apply:

    1. Manual Wheelchair
    2. Cane(s)
    3. Walker
    4. Power Scooter (3 or 4 wheels)
    5. Power Wheelchair

    1. Crutches
    2. Service Animal
    3. None
    4. Other
32. Other

    Please explain.

34. Is your condition temporary?

    1. Yes
    2. No

    If "yes", on what date will your disability no longer prevent you from using CAT bus routes?
36. Date service will no longer be needed
38. What is the disability (diagnosis, illness, injury, condition, etc.) that prevents you from using Charlottesville Area Transit (CAT) bus routes?

    *Sometimes, CAT may ask an applicant to provide additional information regarding a disability in order to determine that applicant's eligibility to use paratransit service.*

40. How does this disability prevent you from using CAT bus routes?
42. Please explain aspects of your disability that you believe CAT should know about.
44. Can you climb three 12-inch steps without assistance?

    1. Yes
    2. No

    1. Sometimes
    2. I Don't Know
46. If "No" or "Sometimes", please explain.
48. What is the farthest distance you can travel without the help of another person?

    1. I CANNOT get to the curb outside where I live.
    2. I CAN get to the curb outside where I live.
    3. 3 blocks (1/4 mile)

    1. 6 blocks (1/2 mile)
    2. 9 blocks (3/4 miles)
50. Is your mobility affected by terrain?
    For example, do steep hills, lack of sidewalks, or other local conditions affect your mobility? Please explain.
52. How long can you wait at a bus stop? Please explain.
54. Is your ability to travel outdoors severely affected by weather, such as:
56. Snow and Ice

    1. Yes

    1. No
58. Extremely hot temperature

    1. Yes

    1. No
60. Extremely cold temperature

    1. Yes

    1. No
62. Other weather condition

    1. Yes

    1. No
64. Please explain "yes" answers.
66. Do you use a personal care attendant (PCA) when you travel?

    1. Yes

    1. No
68. If "Yes", please explain when you need a PCA and what needs a PCA meets when you travel.
70. Is the PCA paid for these services?

    1. Yes

    1. No
72. CAT provides a travel training program that teaches persons with disabilities how to use CAT bus routes. Would you like to receive travel training?

    1. Yes

    1. No
74. What three trips (to and from destinations) do you take most frequently around Charlottesville?

    Please be specific, list street addresses, and/or names of businesses.

76. Trip 1
78. Trip 2
80. Trip 3
82. Print, Sign, and Date

    Print, sign, and date this form. If the applicant is unable to sign, a representative may do so in their place. This form must be mailed or delivered (with an original signature) to the address below:

84. Please provide the phone number of the signee
86. Print Name
90. Signature
94. Date
98. Address

    CAT ADA
    Downtown Transit Station
    615 E Water St
    Charlottesville, VA 22902

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99. Print Only

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