SHUTTLE Eligibility Application
This SHUTTLE application form is NOT to be printed. This template is to be used for individuals using languages other than English as their primary language.
Please use the language feature provided above to view the SHUTTLE application in your preferred language. Please also review SHUTTLE Eligibility and Notice of Privacy Practices
How would you like us to notify you of your eligibility? (Please choose one.)
☐ Send information to me at my mailing address listed below.
☐ Send information to the person and address listed below.
Would you like your eligibility letter sent to you in an alternate format?
☐ Large Print ☐ Audio Tape ☐ Other (specify)
PLEASE COMPLETE ALL QUESTIONS THOROUGHLY
1. What is your physical disability, mental disability, or other qualifying condition?
2. Is this condition temporary?
3. Which of the following mobility aids or equipment do you use when you travel outside your home? Check all that apply.
☐ Manual wheelchair
☐ Powered wheelchair
☐ Walker
☐ Support/quad cane
☐ Service Animal
☐ Other (please specify)
If you use a wheelchair or scooter, what size is it?


Do the combined weight of your wheelchair/scooter and your own weight exceed 600 lbs?
4. How far can you travel on your own or with the use of required mobility aids?
_________Blocks
6. Can you stand for 10 minutes while you wait for your ride?
7. Can you sit for 10 minutes while you wait for your ride?
8. Do you currently use the regular bus service?
☐ No, because:
☐ I have never tried
☐ I have difficult getting on or off the bus.
☐ I have difficulty traveling to and from the bus stops.
☐ I have difficulty recognizing bus stops.
☐ Other (specify)
9. Could you ride the regular bus if there was a bus stop or bus route near your home?
☐ Yes, sometimes:
☐ No
10. Which training would help you to learn to ride the regular bus?
☐ Riding specific bus routes
☐ Traveling to and from the bus stops.
☐ Using the wheelchair lift, ramp, and kneeling features.
☐ Recognizing bus stops.
☐ I have difficulty recognizing bus stops.
☐ Other (specify)
11. Do you need to travel with a Personal Care Attendant (PCA)?
Please read carefully before answering:
- A PCA is somone who travels with you to provide any assistance you need. Your PCA rides free and must board and de-board at the same location as you.
- Pierce Transit operators cannot service as a PCA. Be aware that you will be left alone on the SHUTTLE van while operators are assisting other customers and you will be dropped at your destination whether or not someone is available to meet you. You must arrange for your own PCA.
☐ Sometimes - you travel with a PCA at your own discretion.
☐ Yes - you cannot travel alone or cannot be left alone at a drop off point.
12. Please explain as completely as possible how your disability prevents you from getting on (boarding), riding, or getting off (de-boarding) a regular bus or how it prevents you from getting to the bus line. If your condition is related to an injury or surgery, identify the type of injury or surgery, approximate date and time frame for improvement. If surgery is scheduled, identify date and type of procedure. Add another page if needed.
13. Optional: Please list the 3 trips you travel most frequently. This information will help us better serve your travel needs by providing travel planning in advance.
I certify that the information contained in this application is true and correct to the best of my knowledge. I understand that the purpose of this form is to determine if I am eligible to use SHUTTLE (paratransit) services. I understand that Pierce Transit or its contracted agents may need to contact me or see me later to get more information. I further understand that I must be truthful in answering the questions on this form. Giving false or misleading information is against the law and could result in denial of SHUTTLE eligibility and services. I agree to immediately notify Pierce Transit if I no longer need SHUTTLE services.
Please type or print:
If someone other than the person applying for SHUTTLE eligibility completed this application, that person must provide the following information:
RELEASE OF INFORMATION
Pierce Transit may need to contact your health care/treatment provider for additional information about your condition and your ability to use regular bus service. Please provide the information requested below for each treatment provider most familiar with you. Your treatment provider does not need to sign this form.
Pierce Transit will not release this information to any other person or agency without your permission, except in those instances listed in our Notice of Privacy Practices (included with this application). This release is valid for 6 months, unless revoked in writing earlier.
I authorize the individuals listed below, as well as their office staff, to furnish any information regarding my health, diagnosis, functional capabilities, and treatments that may help Pierce Transit evaluate my application for SHUTTLE service.
(if appropriate and must attach proof of legal guardianship or power of attorney)
Please provide current, relevant doctor, health care, rehabilitiation, vision provider, special education instructor, DDA Case Manager, or mental health treatment provider information. Please identify the general practice type or area of specialty for each source.