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Application for Brandon Access Transit Service

If you have a disability that prevents you from using transit buses some or all of the time, you may be eligible for door-to-door access transit services. An individual who is unable to use the regular transit system, due to a physical, cognitive or functional disability, may be eligible for access services. Access Transit is a shared ride, door-to-door service that operates within the City of Brandon limits. Drivers assist passengers from the exterior door of the pick up location to the exterior door of the destination location. Eligibility Criteria Eligibility is granted based on a reflection of the client’s real needs, which takes into account the client’s ability or inability to use the regular, fixed route transit system. This is determined on the basis of information provided on the application form and, where necessary, through a personal interview. A person may qualify for access transit service for the following reasons:

□ Requires the use of a wheelchair or scooter;

□ Inability to board a regular transit bus (with stairs);

□ Inability to walk one block or to the bus stop nearest their residence;

□ Insufficient endurance or stamina to ride a regular transit bus for a reasonable length of time;

□ Unable to utilize regular transit due to cognitive or physical disability;

*** Elderly and blind persons able to board public transit are not automatically eligible.

1. Please complete the following form as directed. It is important that you understand the eligibility requirements, and that you complete all sections of the form correctly and in full.

2. Section 1, General Information, must be filled out by the applicant or by any other person designated by him or her or an authorized representative if the applicant is unable to act.

3. Section 2, Functional Assessment Form, must be completed and signed by a medical professional (see list of eligible certifications). All assessments must be authorized by the signature of such professional. Please be clear as to the applicant’s ability/inability to use the regular transit system.

4. Please note that filling out this application form does not guarantee eligibility or approval.

5. There is no charge to apply for Access Transit service. Any fees charged by a medical professional are the responsibility of the applicant.

6. Once received, the application will be reviewed and you will be contacted within 5 business days regarding the status of your application. In some cases, additional phone calls or an interview may be required to determine eligibility.

7. If you have any questions, you may call Access Transit Services at (204) 729-2437.

8. Completed forms may be faxed to (204) 729-2485, or mailed to:

ACCESS TRANSIT SERVICE APPLICATIONS

900 RICHMOND AVENUE EAST

BRANDON, MANITOBA

R7A 7M1

Section 1: General Information

Applicant Information

Emergency Contact

List two people we can contact in case of emergency (24 hours a day):
If there is no one at your residence to meet you and you cannot be left alone, you MUST provide an alternate address close by to drop you off at.

All personal and personal health information collected is under the authority of The Freedom of Information and Protection of Privacy Act (FIPPA) and/or The Personal Health Information Act (PHIA) and is protected by the privacy provisions of said Act. All information provided in this form is confidential and solely for the use of Brandon Transit and its agents in determining eligibility for Access Transit service as authorized by the City of Brandon.

Disability Information

3. Is your disability:

Equipment Information

6. If you selected one of the wheelchairs above, please check the device that you will use most often when riding with Access Transit services:
Please provide outside dimensions of your chair. Our wheelchair lifts measure 33” wide x 52” long (83cm x 132cm). Equipment larger than this cannot be accommodated. Please note: Combined weight of passenger & mobility aid must not exceed 750lbs.

Travel Information

Attendants

9. Attendant Required - Access Transit Services may require an attendant to accompany a client for the safety and well being of the client and other passengers. Reasons for requiring an attendant include, but are not limited to, an unstable medical condition such as seizures and/or confusion, disorientation, anxiety, agitation, impaired or limited cognitive functioning and/or communication, and the inability to operate a wheelchair or motorized device independently.

Home Environment

Note: Drivers are only required to assist manual wheelchairs up 1 vertical step. For more than 1 step, you must make alternate arrangements (i.e. ramp).

Certification

I hereby declare that I have a disability that is sufficiently severe such that I am unable without assistance, to use transit buses some or all of the time. I consent to the disclosure of personal information (including medical information) by a medical professional, to Brandon Access Transit or its agents for the purpose of determining my eligibility for Access Transit Service. I will advise Brandon Access Transit or its agents of any changes to my mobility needs. I understand that Brandon Access Transit has the right to review my application from time to time and can revoke my registration if they determine that I am no longer eligible for access transit service.

Choose one of the following (A or B):

A. Applicant Signature

B. Advocate or Spokesperson Completing Form for Applicant

† Designated agencies/representatives include: CNIB, Intermediate or Extended Care Facility Case Manager, Dementia/Geriatric Program Case Managers, Mental Health Case Managers, Community Living Program Social Workers.
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