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Celebrating 30 years of non-profit service to The Santa Clara County
PARATRANSIT ELIBIBILITY APPLICATION
Please print, read, sign, date and mail or drop off at OUTREACH, 926 Rock Avenue, Suite 10, San Jose, CA 95131 (or) FAX to (408) 382-0470. This form may be downloaded in other formats. If you need help completing this form, call OUTREACH and we will be pleased to assist over the phone: 408-436-2865. OUTREACH will contact you for a phone interview.
Section 1: Personal Data
Check one:
 New Applicant:_______    Existing Customer*:______
*If Existing Customer, please provide Outreach ID#:
 ___________________________________________
_ _
Applicant Name:
 ___________________________________________
Circle one:
Mr / Mrs / Ms
Address of Applicant:
___________________________________________
City:
 ___________________________________________
State:
 ___________________________________________
Zip:
 ___________________________________________
Home Phone Number of Applicant:
 ___________________________________________
Mobile Phone Number of Applicant:
 ___________________________________________
Best time(s) to call:
 ___________________________________________

Email:

___________________________________________
Primary Language:
 ___________________________________________
   
Applicant's Assistant's Name:
 ___________________________________________
(if any)
_
Circle one:
Mr / Mrs / Ms
Relationship to Applicant:
 ___________________________________________
Home Phone Number of Person Assisting:
 ___________________________________________
Mobile Phone Number of Person Assisting:
 ___________________________________________
Email of Person Assisting:
 ___________________________________________
   
What is your primary disability and/or most limiting condition?
 ___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Do you use any mobility aids or specialized equipment?
____Yes   ____No
If you answered "Yes" please check all that apply:
 ____Cane ____Manual Wheelchair ____Service Animal
____White Cane ____Power Wheelchair ____Speech Devices
____Walker ____Power Scooter ____Prosthesis
____Crutches ____Leg Braces ____Communication Board
____Respirator ____Portable Oxygen Tank  
Other (specify):_______________________________
Do you need any future written information provided to you in an accessible format?
 ____Yes   ____No
If "Yes", please check the format you prefer:
 ____Email ____Audio Tape ____Large Print
____Diskette ____Braille  
   
Emergency Contact Name:
 ___________________________________________
Relationship to Applicant:
 ___________________________________________
Address of Contact:
___________________________________________
City:
 ___________________________________________
State:
 ___________________________________________
Zip:
 ___________________________________________
Home Phone Number of Contact:
 ___________________________________________
Mobile Phone Number of Contact:
 ___________________________________________
   
Section 2: Applicant Certification (Please Sign)
I certify that the information provided during the application process is true and correct to the best of my knowledge. I understand that falsifying the information will result in a denial of service and may result in criminal penalty.
 
Applicant Signature:
 ___________________________________________
 
Date:
 ___________________________________________
   
Section 3: Authorization for Release of Protected Health Information
I understand the protected health information provided during the application and interview process will be kept confidential and shared only with the following professionals or providers as necessary to determine eligibility and provide paratransit services, and for quality assurance/audits to comply with ADA regulations and VTA policy:  VTA, OUTREACH and their eligibility representatives, and their contractors.
   
Section 4: Authorization to Release Medical Information
(Please include the contact information for your physician or licensed professional, who can verify your disability/ies, or has knowledge about your disability/ies and functional limitations.)
   
I hereby authorize ...
 
   
Name:
 ___________________________________________
Address:
 ___________________________________________
Phone:
 ___________________________________________
FAX:
 ___________________________________________
   
... to release the information requested below about my disability or disabilities to OUTREACH eligibility representatives/contractors upon request. The information released will be used solely to evaluate my eligibility for VTA paratransit services as required by the Americans with Disabilities Act, 42 U.S.C. Section 12101 et seq., 104 Stats. 327.  I understand that I have a right to revoke any Section of this authorization at any time by writing to OUTREACH, except to the extent that action has already been taken based upon this authorization.
   
Applicant Signature:
 ___________________________________________
   
Date:
 ___________________________________________
   

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