ADA Paratransit Application Form

ADA Paratransit serves points of origin and destination within 3/4 of a mile of Space Coast Area Transit’s Fixed Route Service, which includes most of Brevard County from Titusville to Palm Bay. The ADA Certification Form explains how an individual's disability prevents him/her from riding Space Coast Area Transit's Fixed Route Bus System and determines eligibility. The form may be completed by the applicant or by a qualified professional familiar with the applicant's condition. If completed by the applicant, Section 3, Request For Professional Verification, must also be Filled out. Applications in Braille, large type and on tape are also available upon request.

Applicants are eligible for 21 days of service while their ADA Eligibility Certification Form is being processed. Additionally, applicants are eligible for 21 days of out-of-town-service if they have ADA Paratransit Certification from another public entity. After an applicant's ADA Paratransit eligibility is certified, an ADA Eligibility Card and ride-reservation information will be mailed to the applicant within 4 weeks of the date their form was received. The ADA Eligibility Card will be valid for 3 years from date of issue. If eligibility is denied, a letter will be mailed to the applicant explaining the reason for denial and advising him/her of the process to appeal.

To apply, please complete and submit the following online ADA Application form and upload a copy of a State ID as per the instructions below. Alternatively, you may print and manually complete the ADA Application. Please return the signed application, along with a copy of a State ID, to Space Coast Area Transit at 401 South Varr Ave., Cocoa, FL, 32922. If you have any questions, need assistance with the application, or would like to schedule initial service, please contact Customer Service at (321) 635-7815 ext. 52937 or email email us.

Required fields indicated by *

SECTION 1 - PERSONAL INFORMATION

Last Name*:

First Name*:

Middle Initial:

Email*:

Date of Birth*:

Male:

Female:

Phone Number*:

Home:

Work:

Mobile:

Home Address*:

City*:

Sub Division Name:

State*:

Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip*:

Mailing Address (if Different):

Emergency Contact:

Relationship:

Contact's Phone #:

Home:

Work:

Mobile:

Explain nature of disability preventing applicant from using Fixed Route Bus Service*:

Is this condition temporary?*

Yes

No

If Yes, expected time of duration:

Completely explain how disability prevents applicant from using Fixed Route Service*:

Completely explain other relevant effects of applicant’s disablity*:

SECTION 2 - ANALYZATION OF VEHICLE REQUIREMENTS

Check any of the following mobility aids that are applicable to the applicant*:

Not Applicable

Manual Wheelchair

Powered Scooter

Crutches

Electric Wheelchair

Service Animal

Walker

Cane

Oxygen Tank Personal

Care Attendant

Requires personal care attendant to travel via transit*

Yes

No

Can walk 200 feet without assistance of another person*

Yes

No

Can travel ¼ mile without assistance of another person*

Yes

No

Can climb four (4) 12-inch steps without assistance of another*

Yes

No

Can wait outside without support for 10 minutes*

Yes

No

I certify that the information above is true and accurate:

⌫Clear Signature

Applicant's Signature*

Date*

If application was completed by a person other than the applicant:

Name:

Relationship:

Address:

City:

State:

Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Phone:

⌫Clear Signature

Applicant's Signature

Date

SECTION 3 - REQUEST FOR PROFESSIONAL VERIFICATION

In order to confrm eligibility, it may be necessary for Space Coast Area Transit to contact the applicant's healthcare professional. Please complete the following authorization form.

Physician

Rehabilitation Professional

Other

If other:

is familiar with my disability and is authorized to provide information to Space Coast Area Transit required to complete this certifcation

Health Care Professional Name*:

Address*:

City*:

State*:

Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip*:

Phone*:

⌫Clear Signature

Applicant's Signature*

Date*

Only signed applications with a copy of a State ID will be processed.

By electronically signing this document, I affirm, under penalty of perjury, that I am the identified signatory and have full knowledge and consent of the terms and conditions. The attached State ID further verifies my signature and authority, and this electronic signature holds the same legal weight as a handwritten signature.

A valid State Identification Card is required to complete this application. Upload applicant’s State ID below.*

Drag & Drop your file here

or

Browse Files

SECTION 4: FOR OFFICE USE ONLY – REVIEW RESULTS

Date Received:

New Application: (Y/N) Redetermination:

Reviewed by:

Date Approved:

Date Denied:

Reason for Denial:

Letter:

Category Type:

Submit Print