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2. 
3. CityLink Paratransit Service Application

   Please use this application if you are a potential client applying for this service.

    

   If you have a disability which prevents you from being able to use the regular fixed route bus some or all the time, you may eligible for CityLink's Paratransit Service.

    

   All information is kept confidential. Once all the information needed to make an eligibility determination is collected, CityLink will respond to you by mail within 21 calendar days. If it takes longer than 21 days to complete the process you will receive presumptive eligibility until the application process is completed. If you are determined NOT ELIGIBLE for ADA Paratransit Service, you may appeal the decision by submitting a written request to CityLink within 60 days after receipt of your denial letter. It is important that all parts of the application be completed. If the application is not completed it will be returned to you for completion which will delay the application process.

    

   You may e-mail any questions to citylink@abilenetx.gov or call 325-676-6287

5. Personal Information
7. First Name*
8. Middle Initial
9. Last Name*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Mailing Address (if different than address above)
19. City
20. State
21. Zip Code
23. Home Phone*
24. Work Phone
26. Date of Birth*
    Date of Birth
27. Gender
28. Email Address
32. Emergency Contact Information
34. First Name*
35. Middle Initial
36. Last Name*
38. Relationship*
40. Daytime Phone*
41. Evening Phone*
45. Mobility Information
47. Which of these mobility/communication aids or equipment do you use to hep you get where you need to go?*

    Please check all that apply.

    1. None
    2. Cane
    3. Manual Wheelchair
    4. Powered Scooter/Cart

    1. Service Animal
    2. White Cane
    3. Powered Wheelchair
    4. Crutches

    1. Brace
    2. Oxygen
    3. Walker
    4. Prosthesis or Other
49. If Other, please specify
51. With or without the use of mobility aid, how many blocks can you go?*

    1. Less than 2 blocks
    2. 2 to 4 blocks
    3. More than 4 blocks
52. If you were to ride regular fixed route service, would you need a Personal Care Attendant (PCA) with you?*

    1. Always
    2. Sometimes
    3. No
54. Have you ever had any travel training to learn how to use a regular bus?*

    1. Yes
    2. No
55. Would you like to learn how to use the regular bus?*

    1. Yes
    2. No
57. Please explain what conditions would prevent you from traveling using the fixed route service.*
    Example: unpaved areas, distance, health conditions
59. Medical Professional
    A medical professional must complete the CityLink Paratransit Service - Medical Professional Questionnaire to verify your eligibility for Paratransit service. A medical professional may be a doctor, nurse, licensed therapist, social worker, or O&M specialist. Please list the name and fax number of the professional below.
61. Medical Professional's Name*
62. Fax Number*
66. Understanding This Application

    I understand the purpose of this application form is to determine if I, the applicant am eligible to use CityLink ADA Para-transit service according to the guidelines of the American with Disability Act. I understand that this application cannot be processed if it is not complete. I understand that a representative from CityLink may need to talk to me or see me at a later date to clarify or get further information.

     

    I understand that all information will be kept confidential; only the information required will be disclosed to those who perform those services.

     

    I understand CityLink may contact a medical professional on my behalf to assist with the verification of my condition or disability. My signature is consent to provide the necessary information.

     

    I understand the application process can take up to 21 days from the time CityLink receives a completed application. If my application is returned for clarification or additional information, this can delay the process. I will receive notification of the determination of this application.

     

    I certify that the information provided on this application is true and correct to the best of my knowledge. I understand that falsification of information may result in denial of service as well as penalty under law.

68. Signed*
69. Date*
    Date
71. Co-Signed
    Guardian/Person who assisted with this application.
72. Date
    Date
74. Relationship to Applicant
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field