8.17.22 OUTBoard Packet - Laserfiche WebLink

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Orange County Transportation Services ADA Paratransit Plan Orange County Planning Department Page 28 ADA Complementary Paratransit Application—Part A Applicant Information To be completed by applicant or another authorized person, PLEASE PRINT LEGIBLY. Complete all of Part A and sign. Submit to a Health Professional to complete Part B. Date of Application: Last Name: First Name: Middle Initial: Home Address: City: State: Zip: Mailing Address (if different from home address): City: State: Zip: Daytime Phone Number: Evening Phone Number: Cell Phone Number: TTD Number (if applicable): Date of Birth: Gender: ☐Male ☐Female Primary Language: ☐English ☐Spanish ☐Other (please specify): In case of emergency, please contact: Name: Relationship: Daytime Phone: Evening Phone: Name: Relationship: Daytime Phone: Evening Phone: ABOUT YOUR MOBILITY Do you use any of the following mobility aids? (Check all that apply) ☐Other (please describe): If you use a manual, powered wheelchair, or scooter, is it more than 30 inches wide, more than 48 inches long, or does it, when in use, weigh more than 800 pounds (including person plus the mobility device)? ☐Yes ☐No ABOUT YOUR DISABILITY OR LIMITATIONS ☐Cane ☐Manual Wheelchair ☐Picture Board ☐White Cane ☐Powered Wheelchair ☐Alphabet Board ☐Walker ☐Powered scooter/cart ☐Portable Oxygen ☐Crutches ☐Transfer Board ☐Leg/Arm Braces ☐Prosthesis ☐Service Animal ☐None of These 38