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Demand Response Service Application ADA / Dial‐A‐Ride / Flex

Public Transit
Kealy Salomon, Commissioner

 

The information that you provide on this application is intended for the sole purpose of establishing eligibility for transportation service. Dutchess County will not release this information, except to the sponsoring Dial-A-Ride town for other purposes, without your written permission.

*Indicates Required Field

  1. Please check the service(s) for which you are applying:(Check all that apply)

    ADA                                     Dial-A-Ride                                      Flex

  2. Name: *

  3. Street Address:


  4. City/Town/Village:

  5. State:            Zip Code:


  6. Telephone: *   Cell Phone:

  7. Date of Birth: Month Day Year

  8. Municipality of Residence: *

  9. Nearest Intersection:

  10. Please check the reason(s) you are requesting transportation. It is significantly diffcult for me to:
      Walk more than 200 feet
      Stand outside more than 10 minutes
      Negotiate a flight of stairs
      Get on or off a standard bus
      Stand on a moving bus
      Read information due to visual impairment
      Hear announcements made by the bus driver
     Other, please explain


  11. Do you use any of the following aides: (Check all that apply)
    Cane
    Scooter
    Service Animal
    Walker
    Wheelchair
    Other, please explain


  12. Together, how much do you and your mobility device weigh:

  13. Do you travel with a personal care attendant: Yes    No

  14. Do you have special needs the dispatcher should be aware of when scheduling your trips: Yes    No
    If yes, please explain:

  15. Please provide the following information for someone we may contact in case of an emergency: *

    Name:

    Address:

    City:       State:       Zip Code:

    Telephone:

    Cell Phone:

    Relationship to Applicant:




  16. Are you a client of a community service agency:  Yes    No
    If yes, which agency (Please enter Address and Telephone Number):


  17. Please provide the name of a physician or other health care professional as a reference:*

    Name:

    Address:

    City:       State:       Zip Code:

    Telephone:

  18. I state that the information provided in this application is true and complete to the best of my knowledge and agree to release it to Dutchess County for the purpose of establishing my eligibility for transportation service. I also understand that the professional reference named above may be contacted to validate my eligibility.

    Please check this box after reading the statement above.*

 

For further information call: (845) 473-8424

___________________________________________________________________________________

*** Enter the following number in the box below before submitting your Survey:      ***

 

 

Mary Kaye Dolan,Director Mary Kaye Dolan
Director
Dutchess County Seal

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