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Orange County Transportation Services ADA Paratransit Plan <br /> <br />Orange County Planning Department Page 33 <br /> <br />Authorization for Release of Information <br />I authorize the professional who has completed Part B of this application to release to Orange County Public <br />Transit information about my disability or health condition and its effect on my ability to travel on the <br />Orange County Public Transit (OCTS) bus service. I understand that I may revoke this authorization at any <br />time. <br /> <br />I, the applicant, understand that the purpose of this application is to determine my eligibility to use the <br />ADA complementary paratransit services. I agree to release the information requested Orange County <br />Public Transit, and any eligibility review panel, and understand that the information contained herein are <br />treated confidentially, unless otherwise required by law. I understand further that Orange County Public <br />Transit reserves the right to request additional information at its discretion. I agree to notify Orange County <br />Public Transit of any changes in the status of my disability that affects my ability to use the ADA <br />complementary paratransit service. I also understand that this may affect my eligibility as a rider. <br /> <br /> <br />Applicant’s Name <br />Date of Birth <br />Applicant’s Address <br />City State Zip <br />Applicant’s Telephone Number <br />Date <br /> <br />(Signature of Applicant or Responsible Party) <br /> <br />43