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Orange County Transportation Services ADA Paratransit Plan 34 <br /> ADA Complementary Paratransit Application—Part A <br /> Applicant Information <br /> To be completed by applicant or another authorized person, PLEASE PRINT LEGIBLY. Complete all of <br /> Part A and sign. Submit to a Health Professional to complete Part B. <br /> Date of Application: <br /> Last Name: First Name: Middle Initial: <br /> Home Address: <br /> City: State: Zip: <br /> Mailing Address (if different from home address): <br /> City: State: Zip: <br /> Daytime Phone Number: Evening Phone Number: <br /> Cell Phone Number: TTD Number(if applicable): <br /> Date of Birth: Gender: ❑Male ❑Female <br /> Primary Language: ❑English ❑Spanish ❑Other (please specify): <br /> In case of emergency, please contact: <br /> Name: Relationship: <br /> Daytime Phone: Evening Phone: <br /> Name: Relationship: <br /> Daytime Phone: Evening Phone: <br /> ABOUT YOUR MOBILITY <br /> Do you use any of the following mobility aids? (Check all that apply) <br /> ❑Cane ❑Manual Wheelchair ❑Picture Board <br /> ❑White Cane ❑Powered Wheelchair ❑Alphabet Board <br /> ❑Walker ❑Powered scooter/cart ❑Portable Oxygen <br /> ❑Crutches ❑Transfer Board ❑Leg/Arm Braces <br /> ❑Prosthesis ❑Service Animal ❑None of These <br /> ❑Other(please describe): <br /> If you use a manual, powered wheelchair, or scooter, is it more than 30 inches wide, more than 48 inches <br /> long, or does it, when in use, weigh more than 800 pounds (including person plus the mobility device)? <br /> ❑Yes ❑No <br /> ABOUT YOUR DISABILITY OR LIMITATIONS <br /> Orange County Planning Department Page 28 <br />