Rider Alert - Thursday, July 4th - There will be no bus service. In addition -  ROUTE 4, EXPECT DELAYS DUE TO ROADWORK IN COCOA VILLAGE.   RIDER ALERT - ROUTE 21,   DUE TO CONSTRUCTION ON BULLDOG BLVD, STARTING MONDAY JUNE 10th THE BUS WILL BE EXITING THE MELBOURNE SHOPPING CENTER VIA HIBISCUS BLVD. BUS STOPS ON APOLLO BLVD BETWEEN BULLDOG BLVD AND NASA BLVD WILL NOT BE ACCESSIBLE, THERE WILL BE A TEMPORARY STOP ON THE CORNER OF NASA & APOLLO. If you have any questions, please call: 321-633-1878      

Americans With Disabilities Act (ADA) Paratransit Service Application Form

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*:
Phone Number*:
Home:
Work:
Mobile:
Home Address*:
City*:
Sub Division Name:
State*:
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?*
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*:
Requires personal care attendant to travel via transit*
Can walk 200 feet without assistance of another person*
Can travel ¼ mile without assistance of another person*
Can climb four (4) 12-inch steps without assistance of another*
Can wait outside without support for 10 minutes*
I certify that the information above is true and accurate:
Applicant's Signature*
Date*
If application was completed by a person other than the applicant:
Name:
Relationship:
Address:
City:
State:
Zip:
Phone:
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.
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*:
Zip*:
Phone*:
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
Drag & Drop your file here
or

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:
Print

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Americans With Disabilities Act (ADA) Paratransit Service Application Form