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Tri Delta Transit Senior Paratransit Application Packet.

This packet contains the following:

1) Information about Senior Paratransit Service including service area maps (pages 1 - 4)

2) Senior Paratransit Application (pages 5 - 7)

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• You must be 65 years of age or older to receive Senior Paratransit transportation • Senior Paratransit transportation is limited to Tri Delta Transit’s service area in Eastern Contra Costa County (see attached map) • Senior Paratransit transportation operates the following hours

- Monday – Friday 6:30 am to 5:30 pm - Saturday 10:00 am – 5:30 pm - Sunday No service available

• All Rides are subject to availability and are not guaranteed.

For help with the application process, call 925-754-6622 All information that you include on your application will be kept

confidential.

Important Application Information for Senior (Age 65+) Paratransit

Transportation

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Senior Paratransit Application

(Please Print or Type)

Name (first, middle, last): ____________________________________________________________ Home Address: ________________________________ Apt. #: _________ City: _______________________________________________ Zip: ______ Mailing Address (if different from home): ______________________________________________ Apt. #: _________ City: ___________________________________________ Zip: __________ Cell Phone: (_____) _________________ TDD/TTY: (____) ___________ Home Phone: (_____) _______________ Birth Date: ____/____/____ c Female c Male Primary Language (please check): c English c Other (specify)______ If you need any future written information provided to you in an accessible format, please check which format you prefer: c Diskette/CDR c Audio tape c Braille c Large Print c Other In case of emergency, whom should we contact? Name: ___________________________ Relationship: _________________ Cell Phone: (____) _____________Home. Phone: (____) _____________ If there is a medical emergency, where do you want to be transported? Hospital: _______________________________ City: __________________

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Applicant Certification I certify that the information in this application is true and correct. I understand that knowingly falsifying the information will result in denial of service. I understand all information will be kept confidential, and only the information required to provide the services I request will be disclosed to those who perform the services. Sign here: Applicant’s signature ______________________________ Did someone help you in filling out this form? c Yes c No If yes, Name: _____________________________________ Phone: (_____)____________________________________ Relationship: ______________________________________ Do you use any of the following mobility aids or specialized equipment? (Check all that apply): c Cane c Power Wheelchair c Communication Devices c White Cane c Service Animal c Walker c Power Scooter c Crutches c Manual Wheelchair c Leg Braces c Portable Oxygen Tank c Other Aid ______________________________________________

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Paratransit Rider Responsibility Tri Delta Transit is committed to providing safe, secure, and reliable service to our customers. To ensure this level of service, the cooperation and support of our customers is critical. It is for this reason that the following rules have been adopted. I, __________________________________________________ understand that is it my sole responsibility, or that of my Power of Attorney or Conservator to contact Tri Delta Transit with any of the following changes during the course of my registration with Tri Delta Transit’s paratransit service: • My name, address and/or telephone number • Emergency contact’s name and/or phone number • Type of mobility device • Change(s) to physical or mental condition • Need for a personal care attendant _____________________________________________________ Signature

_____________________________________________________ Date Please note: All three pages of this application must remain attached. If the application is received without all three pages, it will be considered incomplete.