Application

Personal Information

First Name

Middle Initial

Last Name

Address

City

State

Zip Code

Date of Birth

Home phone

Work phone

Gender

Mailing Address (If Different)

Address

City

State

Zip Code

How did you learn about the GO!Bus Service?

The Environment Around Your Home

Are there sidewalks by your residence?

Are there curb cuts by your residence?

Current Travel

How long have you lived in the Grand Rapids area?

List your four most frequent destinations and how you get there now:

Destination	Frequency of Travel	How You Get There Now

Have you ever used any fixed-route bus service (the city bus)?

If yes, under what circumstances (explain where and why?)

If no, what prevents you from using the fixed-route (city bus) bus service?

Where is the closest bus stop to your residence? (Please give the location)

Can you get to The Rapid bus stop by yourself?

If no, why not?

If someone showed you how to use the fixed-route bus (city bus), could you?

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...?)

If no, why not?

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

Is this condition temporary?

Physical Ability

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

Can you currently travel by yourself?

How long can you wait outside without support?

Do you require someone to help you when you leave home?

If yes, please explain what the person does to help you.

Can you use a wheelchair accessible Rapid city bus?

If no, why not?

Have you ever received training in the use of the items checked above? If so, by whom and when?

Walk up and down three steps if there are handrails on both sides?

Travel one level block on the sidewalk when the weather is good?

If you are able to do this, how long does it take you?

Cross the street, if there are curb cuts?

Cross the street, if there are no curb cuts?

Safely cross the street?

If you cannot safely cross a street, please explain why.

Stand on a moving bus?

Wait up to 30 minutes in good weather, outdoors without a place to sit?

Step up and down from a curb?

Find your own way to the bus stop?

Currently travel by yourself?

Have you ever gotten lost when traveling alone?

If yes, please explain

Have you ever had a seizure?

If yes, when was your last seizure and what type was it?

Do you know when a seizure is coming (aura)?

Cognitive Conditions

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

Give Name

Give Address

Give Phone

Safely cross streets and intersections?

Recognize familiar places/destination/landmarks or bus stops?

Ask for assistance when needed

Understand written/oral directions?

Find your way to/from bus stop?

Make a transfer from bus to bus with assistance?

Make a transfer from bus to bus without assistance?

Use the telephone to get information?

Additional comments

Person to contact in case of emergency

Name

Relationship

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.

Please Verify:

If this application has been completed by someone other than the person requesting certification, please complete the following:

Name

Relationship

Address

City

State

Zip Code

Phone

Fax

Email

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

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Mailing Address (If Different)