Access A Ride Application Pdf Details

When you need to take a trip and don't have access to a car, or when you just want an easy, affordable way to get around town, the application access ride form is the perfect solution. With this convenient service, you can easily hail a ride from your phone. Plus, there are no extra costs or fees associated with using this service. So whether you're going to work, the grocery store, or running errands, application access rides will get you where you need to go. Check out this quick guide to learn more about how it works.

The listing has got details about the application access ride. Prior to fill in the form, it is definitely worth studying more details on it.

QuestionAnswer
Form NameApplication Access Ride
Form Length10 pages
Fillable?Yes
Fillable fields297
Avg. time to fill out30 min 59 sec
Other namesaccess a ride application, access a ride service, access a ride, for access a ride

Form Preview Example

MN

ACCESS-A-RIDE SERVICE APPLICATION

New Application

Recertification: ID Number ____________________________

MTA New York City Transit’s paratransit service, Access-A-Ride, provides door-to-door transportation within New York City on an advance reservation basis to persons who, because of a physical or mental disability, are unable to use public transit buses or subways.

INSTRUCTIONS

You must complete this application and bring it with you to the scheduled evaluation at the offices of the professional certifier selected by NYC Transit listed in the cover letter. Please give the completed application and any supporting documents to the professional certifier.

If a question does not apply to you, clearly mark N/A in the space provided. If you have any questions while completing this application, please call 877-337-2017 and when the recorded message begins press “1” for English and “1” for Eligibility. If you are unable to complete the form yourself, it can be completed by someone you choose to assist you. It may take up to 3 weeks to process your application.

One (1) photograph taken within the last three years must be submitted with this application for use on your identification card. Please see the box below for required size. The photograph must have a solid background and show a full view of your face. Please write your name on the back of the photograph. If you do not bring

the photograph with you to the evaluation center, the application process cannot be completed.

All of the information you provide will be used solely for the purpose of determining your eligibility, and any special assistance you may need when using paratransit. The information that you furnish will be kept strictly confidential.

Once issued, an Access-A-Ride paratransit service card expires five (5) years from the date it was issued, unless otherwise indicated.

Do you need information in an alternate format?

Check one: Large Print

Audio Tape

Braille

 

 

 

 

 

 

 

E-mail _________________________________

 

2"

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

Your evaluation will not take place if you arrive at the evaluation

 

 

 

 

 

 

 

center with an incomplete application. You will have to

 

 

 

 

 

 

 

reschedule your evaluation and you may not be provided with

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 1/2"

 

 

transportation for the rescheduled evaluation.

 

 

 

 

 

 

For External Certifier’s Use

Initials _________________________

Date ____________________________

For NYCT Office Use

Application #: ______________________

Date Entered: ______________________

By: ______________________________

1

AGREEMENT TO ELIGIBILITY TERMS AND CONDITIONS (ALL APPLICANTS MUST SIGN THIS AGREEMENT)

I understand that as a part of the application process I must attend an in-person evaluation at the offices of a professional certifier selected by NYC Transit.

I understand that MTA NYC Transit reserves the right to request additional proof of my disability or my inability to use public buses and subways.

I understand that my application will not be accepted at the evaluation center if it is not complete.

I affirm that all of the information that I provide on this application is true to the best of my knowledge. I understand that my application is subject to review and verification, including verification after my Access-A-Ride card has been issued, and that misrepresentation of any material information will lead to termination of my eligibility.

I agree to notify NYC Transit at 877-337-2017 if I no longer need paratransit service for any reason, including a change in my ability to use bus and subway service. I also understand that my failure to cooperate with a request for additional information to verify statements made on my application after my Access-A-Ride card has been issued will be grounds for suspension or termination of my eligibility for paratransit service. I further understand that my failure to adhere to the policies and procedures for using Access-A-Ride are also grounds for suspension or termination of my eligibility for paratransit service.

_____________________________________________

_____________________________________________

Applicant’s Signature

Date

If someone other than the applicant has completed this application, please provide the following information:

_____________________________________________

_____________________________________________

Name

Relationship to Applicant

_____________________________________________

_____________________________________________

Telephone Number

Date

2

REQUIRED IDENTIFICATION INFORMATION (PLEASE PRINT CLEARLY)

____________________________________ ____________________________________

___________

Last Name

First Name

 

 

M.I.

________________________________________________________

______________________________

Street Address

 

 

Apt. No.

 

_______________________________________________

_______

_______________________________

City/Borough

 

State

Zip Code

 

________________________________________________ and ____________________________________________

Cross Streets

___________-_____________-_____________________

__________-_____________-______________________

Home Telephone Number

 

Work Telephone Number

______________________________________________

__________-_____________-______________________

E-mail Address

 

Cell Phone Number

_________-__________-__________

Sex: ______

______

Date of Birth

Male

Female

If your mailing address is different from your home address, please complete the following:

(Otherwise leave blank)

____________________________________________________________

_____________________________

P.O. Box or Street Address

 

Apt. No.

 

______________________________________________________

________________

__________________

City/Borough

State

 

Zip Code

Person to Contact in Case of Emergency: (This section must be completed.)

____________________________

____________________________ _______

Last Name

First Name

M.I.

_____________-____________-__________

_____________-____________-__________

Home Telephone Number

 

Work Telephone Number

Relationship to Applicant: _______________________________________

3

APPLICATION FORM

1.How do you currently travel? (Check all that apply)

Public Transit Bus Subway School Bus Walking Automobile

Access-A-Ride Commuter Railroad

Ambulette

Taxi/Car Service

Other: ____________________________________________

2.Are you registered with the MTA Reduced-Fare program?

Yes

No

3.Do you have a MetroCard? (Check all that apply)

Yes, I use my MetroCard when traveling by bus

Yes, I use my MetroCard when traveling by subway

No, I don’t have a MetroCard

4.Is your disability:

Permanent Temporary I don’t know

5.If temporary, please indicate how long you believe the temporary disability will continue.

2 months 3 months 6 months

Other (Specify): ___________________________________

6.Indicate which support device(s) you use when traveling or walking outside your home.

I do not require a support device

Respirator/Oxygen Tank

Walker

Braces

Support Cane

Scooter*

Crutches

Prosthesis

Service Animal (an animal that provides assistance)

Manual Wheelchair*

Motorized Wheelchair*

Other (Specify) ______________________________________________

*Access-A-Ride vehicles can only accommodate a wheelchair or scooter that is less than 33.5 inches in width and 51 inches in length and does not weigh more than 800 pounds when occupied.

7.If you have a service animal, indicate the tasks(s) your service animal performs for you.

Guides me (vision impairment)

Alerts me (hearing impairment)

Pulls me (manual wheelchair)

Carries items for me

Other (Specify): _____________________________

8.Have you received training to use public transit buses or subways?

Yes

No No, I would like training

I am in the training process

4

9.Would you be able to travel by bus or subway if Access-A-Ride took you from: (Check all that apply)

your home to a bus stop

the bus stop to your home

your destination back to the bus stop

your home to an accessible subway station

the accessible subway station to your home

your destination back to the accessible subway station

Not applicable

10.a. How far from your home is the nearest public transit bus stop?

Less than 1 block 1 to 2 blocks 3 to 4 blocks 5 or more blocks

Identify location of public transit bus stop:

___________________________________________________________________________

b. How long does it take you to walk to the nearest public transit bus stop?

Less than 5 minutes

5-10 minutes

More than 10 minutes

Not sure

11.On your own or using a support device, are you able to get to and from the public transit bus stop nearest your home?

Yes

No

Sometimes—describe the circumstances:

___________________________________________________________________________

12.On your own or using a support device, can you get on, ride, and get off a public transit bus when the “kneeler” is lowered (a kneeler is a device that lowers the front of the bus)?

Yes

No

Sometimes—describe the circumstances: _______________________________________________________________________________

13.How often do you travel on public transit buses?

Daily Weekly Monthly

Occasionally Never

If you have used a public transit bus in the past, when did you stop?

____________ (Mo./Yr.)

Why did you stop traveling by public transit bus?

_________________________________________________________________________________________________________________

14.If you cannot walk up the steps on a bus or use the kneeler, are you able to use the bus lift? (Please note that persons who cannot climb the bus steps have the right to enter the bus by standing on the lift.)

Yes No

Sometimes Don’t Know

5

15.Are you able to identify and understand the destination and route number signs on public transit buses?

Yes

No

Only when the bus operator announces them

Sometimes—describe the circumstances: _______________________________________________________________

16.Are you able to determine when you have reached your destination to get off the public transit bus?

Yes No

Only when the bus operator announces the stop

Sometimes—describe the circumstances:

______________________________________________________________________________________________________________________________________________________________________

17.a. How far from your home is the nearest subway station?

Less than 1 block 1 to 2 blocks

3 to 4 blocks 5 or more blocks

Identify location of subway station:

_______________________________________________

_______________________________________________

b. How long does it take you to walk to the nearest subway station?

Less than 5 minutes

5-10 minutes

More than 10 minutes

Not sure

18.On your own or using a support device, are you able to get to and from the subway station nearest your home?

Yes

No

Sometimes—describe the circumstances:

_________________________________________________________________________________________________________

19.On your own or using a support device, can you ride on an escalator?

Yes No

Sometimes—describe the circumstances: _________________________________________________________________

20.On your own or using a support device, are you able to go to and from the station platform and the street entrance?

Yes

No

Sometimes—describe the circumstances: _____________________________________________

Only if equipped with an elevator

21.On your own or using a support device, how far can you travel on a level street? Please answer in city blocks.

Less than 1 block

1 to 2 blocks

3 to 4 blocks

5 or more blocks

22.On your own or using a support device, can you get on, ride and get off a subway train?

Yes No

Sometimes—describe the circumstances: ________________________________________

6

23.Are you able to determine surfaces (platform, top or bottom of stairs) in a subway station?

Yes No

Sometimes—describe the circumstances: ______________________________________________________

24.Are you able to identify and understand the destination and subway line signs?

Yes No

Sometimes—describe the circumstances:

_______________________________________________________

25.Are you able to determine when you have reached your destination to get off the subway?

Yes No

Sometimes—describe the circumstances:

______________________________________________________

Only when the conductor announces the stop

26.How often do you travel using the subway?

Daily Weekly Monthly Occasionally

Not at All

If you have used the subway in the past, when did you stop using it?

___________(Mo./Yr.)

Why did you stop traveling by subway?

______________________________________________________________________________

______________________________________________________________________________

27.a. Do you currently travel with a Personal Care Attendant (PCA), a person such as a home attendant who assists you regularly when you travel outside your home?

Yes

No

Sometimes—describe the circumstances:

__________________________________________________________________________________

__________________________________________________________________________________

I don’t have a Personal Care Attendant

b.If you do need the assistance of a PCA to travel, what kind of traveling assistance does the PCA provide and what specifically does the PCA do for you when he/she travels with you?

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

7

28.If you are unable to take some or all of your trips by public transit bus or subway, check off the reasons below. (Check all that apply)

Not applicable

I feel unsafe traveling by public transit bus

I do not like traveling by city buses

Distance to public transit bus is too long

I do not like traveling by subway

I feel unsafe traveling by subway

Distance to subway is too long

Subway station has no elevators

No curb cuts

No paved sidewalks

Inclement weather

Extreme cold

Hilly streets

Extreme heat

I cannot travel to an unfamiliar place

(The application continues on Page 9).

8

29.a. From the following list, please check off all disabilities or conditions that prevent you from boarding, riding or disembarking from public transit buses or subways.

Cardiovascular/Pulmonary

 

Neuromuscular

 

 

Angina

 

 

___

ALS/Lou Gehrig’s Disease

 

___

Arteriosclerosis/Atherosclerosis

___

Cerebral Palsy

 

___

Asthma

 

 

___

Charcot-Marie Tooth Syndrome

___

Bypass Surgery:

Date: _________________

Equilibrium

 

___

Chronic Obstructive Pulmonary Disease

___

Fibromyalgia

 

___

Congestive Heart Failure

 

___

Hemiplegia/Hemiparesis

 

___

Cystic Fibrosis

 

 

___

Multiple Sclerosis

 

___

Emphysema

 

 

___

Muscular Dystrophy

 

___

Heart Attack:

Date: _________________

Neuropathy

 

___

HTN/Hypertension

 

 

___

Paraplegia

 

___

Peripheral Vascular Disease

___

Parkinson’s Disease

 

___

Phlebitis

 

 

___

Polio

 

___

Thrombosis

 

 

___

Quadriplegia

 

___

Other: ___________________________________

Sciatica

 

___

 

 

 

 

Spina Bifida

 

___

General Medical

 

 

 

Stroke/Cerebral Trauma:

Date: ___________

AIDS

 

 

___

TIA’s (Transient Ischemic Attack)

___

Atrophy

 

 

___

Other: ___________________________________________

Chemotherapy Treatment dates: _______________

 

 

 

_________________________________________

Orthopedic

 

 

Diabetes

 

 

___

Amputation: specify extremity (ies) __________

Edema

 

 

___

_________________________________________________

Epilepsy

 

 

___

Broken/Fracture: __________ Date: ___________

HIV

 

 

___

Degenerative Joint Disease

 

___

Lupus

 

 

___

Gout

 

___

Rheumatoid Arthritis

 

 

___

Hip Replacement

 

___

Kidney Dialysis

 

 

___

Knee Replacement

 

___

Radiation Treatment dates: ___________________

Osteoarthritis

 

___

________________________________________

Osteoporosis

 

___

Other: __________________________________

Scoliosis

 

___

 

 

 

 

Spondylitis

 

___

Vision [Specify eye (s)]

One Eye

Both Eyes

Other: __________________________________

Cataracts

 

___

___

 

 

 

Cortical Blindness

 

___

___

Cognitive/Psychological

 

Glaucoma (all types)

 

___

___

Alzheimer’s Disease

 

___

Macular Degeneration

___

___

ADD/Attention Deficit Disorder

___

Retinal Detachment

 

___

___

Autism

 

___

Legally Blind

 

___

___

Dementia

 

___

Totally Blind

 

___

___

Head Trauma

 

___

Other: ________________________________

Mental Retardation

 

___

 

 

 

 

Panic Disorder

 

___

 

 

 

 

Schizophrenia

 

___

 

 

 

 

Other: __________________________________

9

Toll free from area codes 212, 646, 718, 347, 516, 631, 914, 845
(Press “1” for English and “1” for Eligibility when the recorded message begins.) From all other area codes

b. For each disability or condition checked on previous page, please describe how it prevents you from boarding, riding or disembarking from public transit buses or subways. You may also include medical documentation to support your disability.

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

c. Bring a copy of medical documentation that verifies your transportation related disability to the in-person assessment.

CHECK HERE IF YOU ARE NOT BRINGING MEDICAL DOCUMENTATION TO THE IN-PERSON ASSESSMENT.

30.From your residence, what are the addresses of your three (3) most frequent destinations?

 

 

 

 

 

How Often Do You Travel

 

 

 

 

 

To This Location (Specify)?

Destination Address

 

Cross Streets

Borough

Daily

Wkly

Mthly

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have any questions, please contact Access-A-Ride Customer Information between 9 AM and 5 PM, Monday through Friday.

877-337-2017

718-393-4999

Customers who are deaf call through the relay.

PLEASE REMEMBER THAT YOU MUST:

Submit one (1) photograph measuring 2" x 11/2" that has been taken within the last three (3) years.

Complete and sign the Agreement section.

Complete the application answering every question, and bring it with you when you go to the evaluation center.

10

134_10__14pt_MA

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