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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

Last Name
First Name
Home Address
Apt #
 
Name of Complex
City
State
Zip Code
Home Phone #
Date of Birth
Male ☐   Female ☐
Emergency Contact
Phone #

How would you like us to notify you of your eligibility? (Please choose one.)

☐ Send information to me at my home address above.
☐ Send information to me at my mailing address listed below.
☐ Send information to the person and address listed below.
 
Name
Mailing Address
City
State
Zip

Would you like your eligibility letter sent to you in an alternate format?

☐ No
☐ Yes, in the following 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?

☐ No
☐ Yes (for how long)

3. Which of the following mobility aids or equipment do you use when you travel outside your home? Check all that apply.

☐ I do not use any
☐ Manual wheelchair
☐ Powered wheelchair
☐ Powered scooter
☐ Walker
☐ Support/quad cane
☐ White Cane
☐ Service Animal
☐ Other (please specify)

If you use a wheelchair or scooter, what size is it?

_________Length in inches
_________width in inches

Do the combined weight of your wheelchair/scooter and your own weight exceed 600 lbs?

☐ No
☐ Yes

4. How far can you travel on your own or with the use of required mobility aids?

_________Blocks

5. What is the factor that limits your ability to travel?

6. Can you stand for 10 minutes while you wait for your ride?

☐ Yes
☐ No

7. Can you sit for 10 minutes while you wait for your ride?

☐ Yes
☐ No

8. Do you currently use the regular bus service?

☐ Yes
☐ 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, always
☐ Yes, sometimes:
☐ No

10. Which training would help you to learn to ride the regular bus?

☐ Getting on or off the 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.
☐ No - you may still have someone travel with you whenever you wish.
☐ 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.

Starting Address
Ending Address
Times per Month

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.

Applicant Signature
Date
Signature
Date
Signature of individual completing form if not applicant.

Please type or print:

If someone other than the person applying for SHUTTLE eligibility completed this application, that person must provide the following information:

Last Name
First Name
Relationship to Applicant
Daytime Phone #
Company Name

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.

Applicant Signature
Birthday
Date
Applicant Social Security
Legal Guardian Signature
Phone #

(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.

Name
Profession
Address
Phone #
Name
Profession
Address
Phone #
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Trip Planner Help

Trip Planner Tips - Entering Locations

To create a trip plan you need to enter both a starting location (origin) and an ending location (destination). For information about stops, schedules, or service at a specific location, you only need to enter one location.

The Trip Planner recognizes most street intersections and addresses as well as many landmarks in Pierce, King, and Snohomish Counties. If what you entered is not immediately recognized, the Trip Planner will offer you a list of options. You can choose one of the options, but if your intended location is not there, select the "Revise Original Entries" link to return to the entry page and change the entries you have already made.

Addresses

  • You don't need to type in the city along with the address. The Trip Planner shows the possible city names as options if needed. City names are based on zip codes.
  • You don't need to type in St., Street, Ave., or Avenue, or similar street types. The Trip Planner shows the possible alternatives as options if needed. (Example: type 110 Jones instead of 110 Jones Boulevard.)
  • You don't need to type in the directional designations for streets, but if a direction name is part of a street name, you should include it. (Example: type 1000 Main instead of 1000 S Main. But type 1000 West Viewmont for 1000 West Viewmont Way W.)
  • Some streets and addresses are unknown to the Trip Planner. You may need to enter another nearby location, such as an intersection or a landmark.
  • You should not enter the suite number or apartment number.  Just the house number and street name (Example: type in 401 Broadway instead of 401 Broadway Avenue Suite 800).

Intersections

  • The "&" symbol is the only character used between two street names to show an intersection. (Examples: 1st & B, James & Madison)
  • You don't need to type in the city. The Trip Planner shows the possible city names as options if needed. City names are based on zip codes.
  • You don't need to type in St., Street, Ave., or Avenue, or similar street types. The Trip Planner shows the possible alternatives as options if needed. (Example: type Conifer & Jones instead of Conifer Circle & Jones Boulevard.)
  • You don't need to type in the directional designations for streets, but if a direction name is part of a street name, you should include it. (Example: type 3rd & Main instead of 3rd S & S Main. But type 34th & West Viewmont for 34th W & West Viewmont Way W.)
  • Some streets are unknown to the Trip Planner. You may need to enter another nearby intersection or a landmark.

Landmarks

Government Sites: Pierce County Health Dept, Pierce Co Sheriffs Office, Tacoma City Hall

Major Commercial Sites: Tacoma Mall, Sheraton Hotel

Transportation Facilities: Sea-Tac Airport, Greyhound Bus Depot

Schools & Colleges: Pacific Lutheran University, Tacoma Community College

Sports & Leisure: Cheney Stadium, Pt Defiance Zoo

Medical Facilities: Group Health, Tacoma General Hospital


 

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