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2. Point Plus Eligibility Application / Specialized Transportation Certification
   The information obtained in this certification will only be used for the provision of Central Transportation specialized transportation services.
4. 1. What services are you applying for? *

   (Please Check All that Apply)

   1. Point Plus Paratransit
   2. Portage County Transportation (Rural Bus, Taxi, Volunteer)
6. First Name*
7. Middle Initial
8. Last Name*
10. Address*
11. City*
13. State*
14. Zip Code*
16. E-mail Address
18. Name of Residence/Building Complex
20. Date of Birth (mm/dd/yyyy)*
21. Phone Number*
22. Gender

    1. Male
    2. Female
24. Emergency Contact Name*
25. Emergency Contact Phone Number*
27. 1. Are you on medical assistance?*

    Otherwise known as Medicaid, Title XIX or MA. Not to be confused with Medicare.

    1. Yes
    2. No
29. 2. Are you a member of any of the following social service agencies?

    (Please check all that apply)

    1. IRIS
    2. MTM
    3. Inclusa
    4. Lakeland
    5. None
    6. Other
31. If "Other," list the agencies:
33. 3. Please check which best describes your current living situation:*

    1. I live independently (without the assistance of another person)
    2. I live with family members who help me
    3. I receive assistance from someone that comes to my home to help with daily activities
    4. Assisted Living Facility
    5. 24-hour care or Skilled Nursing Facility
35. 4. What is your disability or medical condition? (Do not abbreviate or use acronyms.)
37. 5. Is this condition temporary?

    1. Yes
    2. No
39. If "Yes," expected duration of condition is:
41. 6. Which of the following mobility aids do you use?

    (Please check all that apply)

    1. Manual Wheelchair
    2. Scooter
    3. White Cane
    4. Power Wheelchair
    5. Walker
    6. Portable Oxygen
    7. Cane
    8. None
    9. Other
43. If "Other," please describe:
45. If you use a wheelchair or scooter, please provide the following information about the device.
    (Please note, individuals using mobility devices that exceed 30” in width and/or 48” in length may not be able to be accommodated. Also in situations where the applicant and their mobility device have a combined weight of more than 800 lbs. when occupied, Central Transportation may not be able to accommodate the ride.)
47. Make/Model
49. Length
50. Width
51. Weight
53. 7. How far can you travel with or without the use of a mobility aid?

    1. I cannot travel outside my house/apartment
    2. I can get to the curb in front of my house/apartment
    3. I can travel up to 3 blocks
    4. I can travel up to 6 blocks
55. 8. How do you currently travel?

    (Please check all that apply)

    1. Someone drives me
    2. I drive myself
    3. Paratransit
    4. Taxi
    5. City Bus
    6. Other
57. If "Other," please explain:
59. 9. Do you travel with a Personal Care Attendant?*

    1. Yes
    2. No
61. 10. Can you wait outside at a bus stop for 10-15 minutes?

    1. Yes
    2. No
    3. Sometimes
63. 11. If you use a mobility device (e.g. wheelchair) can you get on and off a wheelchair lift independently?

    1. Yes
    2. No
65. 12. Is your ability to travel affected by physical or natural barriers (distance, weather, lack of curbs, etc.)?

    1. Yes
    2. No
67. If “Yes”, please explain:
69. 13. Mark the box if it describes you.

    (Please check all that apply)

    1. I have a disability which prevents me from boarding the City Bus.
    2. I have a disability which prevents me from getting to a bus stop.
    3. I have no experience with the City Bus.
    4. There is no bus stop near my residence.
71. 14. Mark the box if it describes you.

    (Please check all that apply)

    1. I can read informational signs.
    2. When I travel, I can find my way around by myself.
    3. I can ask, understand, and follow directions.
73. 15. If personalized travel training were provided to teach you how to ride the City Bus, would you participate?

    1. Yes
    2. No
75. Professional Verification
    In order for your application to be evaluated, it may be necessary to contact a physician or other professional to confirm the information you have provided. Please complete the following information and authorization form.
77. The following professional is most familiar with my health condition and is authorized to provide Central Transportation with the information required to complete this certification.
    Registered Nurse, Case Manager, Rehabilitation Professional, Physical Therapist, Occupational Therapist, Mental Health Professional.
79. Professional(s) Name
80. Facility
82. Address
83. City
85. State
86. Zip Code
87. Phone
89. I hereby authorize the above professional to provide the required information to Central Transportation. Furthermore, I understand it may be necessary for me to participate in an in-person evaluation to determine my eligibility for specialized transportation services. I certify that the information may result in denial of service.

    1. I Agree
91. I hereby agree that the information given is correct.*

    1. I Agree
93. To the best of my knowledge the above information is true and factual. I understand that falsification, distortion, or misrepresentation of information may result in denial of service. *

    1. I Agree
95. If this application has been completed by someone other than the person requesting certification, provide the following information:
97. Name
98. Phone
Leave This Blank:


100. 1. Receive an email copy of this form.
101. Email address

     This field is not part of the form submission.

102. Submit Submit and Print

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