GO!Bus Application

Personal Information

1. First Name
2. Middle Initial
3. Last Name
4. Address
5. City
6. State - Choose - AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY ZZ
7. Zip Code
8. Date of Birth
   (mm.dd.yy)
9. Home phone
10. Work phone
11. Gender - Choose - Male Female

The Environment Around Your Home

1. Are there sidewalks by your residence? - Choose - Yes No
2. Are there curb cuts by your residence? - Choose - Yes No

Current Travel

1. How long have you lived in the Grand Rapids area?

2. List your 4 most frequent destinations and how you get there now:

   	Destination	Frequency of Travel	How You Get There Now
   #1	Destination 1	Frequency 1	Current Method 1
   #2	Destination 2	Frequency 2	Current Method 2
   #3	Destination 3	Frequency 3	Current Method 3
   #4	Destination 4	Frequency 4	Current Method 4
3. Have you ever used any fixed-route bus service (the city bus)? - Choose - Yes No Sometimes
4. If yes, under what circumstances – explain where and why?
5. If no, what prevents you from using the fixed-route (city bus) bus service? - Choose - closest bus stop too far don't know where the bus stop is can't get to the bus stop by myself don't want to afraid don't feel safe
6. Where is the closest bus stop to your residence? (Please give the location)
7. Can you get to The Rapid bus stop by yourself? - Choose - Yes No Sometimes
8. If no, why not?
9. If someone showed you how to use the fixed-route bus (city bus), could you? - Choose - Yes No
10. If the weather is good and there are no barriers in the way, what is the farthest you can walk or travel outdoors on a level sidewalk using your mobility aid (wheelchair, cane, etc...?) - Choose - I cannot travel outdoors alone at all Curb in front of my house Less than one block 2 blocks or 200 feet 4 blocks or 1/4 mile 8 blocks or 1/2 mile More than 8 blocks Not sure Other - Explain in text box
11. If no, why not?

12. What is your disability? (Disability is defined as a physical or mental impairment that substantially limits one or more activities.)

    	Disability	Reason/Cause of Disability
    #1	Disability 1	Cause 1
    #2	Disability 1	Cause 2
    #3	Disability 3	Cause 3
    #4	Disability 4	Cause 4
13. Is this condition temporary? - Choose - Yes No

Physical Ability

The following set of questions pertain to your physical capabilities only.

1. Can you currently travel by yourself? - Choose - Yes No Sometimes Not Sure
2. How long can you wait outside without support? - Choose - 0 to 10 minutes 10 to 20 minutes More than 20 minutes Not Sure
3. Do you require someone to help you when you leave home? - Choose - Yes No Not Sure
4. If yes, please explain what the person does to help you.
5. Can you use a wheelchair accessible Rapid city bus? - Choose - Yes No Sometimes
6. If no, why not?

7. Do you use any of the following aids for mobility? (Check all that apply)

   1. Manual Wheelchair
   2. Power Scooter
   3. Walker
   4. Cane
   5. Portable Oxygen

   1. Electric Wheelchair
   2. Braces or Crutches
   3. Guide or
      Service Animal
   4. White Cane
   5. None of the Above
8. Have you ever received training in the use of the items checked above? If so, by whom and when?
9. Walk up and down three steps if there are handrails on both sides? - Choose - Always Sometimes Never Not Sure
10. Travel one level block on the sidewalk when the weather is good? - Choose - Always Sometimes Never Not Sure
11. If you are able to do this, how long does it take you? - Choose - Less than 5 minutes 5 to 10 minutes Not Sure
12. Cross the street, if there are curb cuts? - Choose - Always Sometimes Never Not Sure
13. Cross the street, if there are no curb cuts? - Choose - Always Sometimes Never Not Sure
14. Safely cross the street? - Choose - Always Sometimes Never Not Sure
15. If you cannot safely cross a street, Please explain why.
16. Stand on a moving bus? - Choose - Always Sometimes Never Not Sure
17. Wait up to 30 minutes in good weather, outdoors without a place to sit? - Choose - Always Sometimes Never Not Sure
18. Step up and down from a curb? - Choose - Always Sometimes Never Not Sure
19. Find your own way to the bus stop? - Choose - Always Sometimes Never Not Sure
20. Currently travel by yourself? - Choose - Always Sometimes Never Not Sure
21. Have you ever gotten lost when traveling alone? - Choose - Yes, explain below I never travel outside alone No, I've never gotten lost
22. If yes, please explain
23. Have you ever had a seizure? - Choose - Yes, No Sometimes
24. If yes, when was your last seizure and what type was it?
25. Do you know when a seizure is coming? (aura) - Choose - Yes No

Cognitive Conditions

Please mark all of the categories below as they relate to your disability. Can you:

1. Give Name - Choose - Yes No
2. Give Address - Choose - Yes No
3. Give Phone - Choose - Yes No
4. Safely cross streets and intersections? - Choose - Yes No
5. Recognize familiar places/destination/landmarks or bus stops? - Choose - Yes No
6. Ask for assistance when needed - Choose - Yes No
7. Understand written/oral directions? - Choose - Yes No
8. Find your way to/from bus stop? - Choose - Yes No
9. Make a transfer from bus to bus with assistance? - Choose - Yes No
10. Make a transfer from bus to bus without assistance? - Choose - Yes No
11. Use the telephone to get information? - Choose - Yes No
12. Additional comments

Person to contact in case of emergency:

1. Name
2. Relationship to applicant
3. Phone

Acknowledgement and Verification

Whoever knowingly and willfully falsifies or conceals a material fact, shall be fined not more than $10,000 or imprisoned more than five (5) years or both (18 USC Section 1001, 1982) Under penalty of law, I hereby certify that the information given above is correct.

1. Please verify: -- Choose -- Yes No
2. If this application has been completed by someone other than the person requesting certification, please complete the following:
3. Name
4. Relationship
5. Address
6. City
7. State - Choose - AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY ZZ
8. Zip Code
9. Phone
10. Fax
11. Email

Please remember that the professional verification form must also be submitted before this application is considered complete and can be reviewed.