Application #_______

 

Central Fraser Valley - handyDART

Eligibility for handyDART and Taxi Saver Programs

 

NOTE:  ALL INFORMATION THAT YOU PROVIDE WILL BE HELD IN STRICT CONFIDENCE BY CENTRAL FRASER VALLEY  handyDART.

 

If you have a disability which prevents you from using accessible fixed route transit service some or all of the time, you may be eligible for the Central Fraser Valley Transit System’s door to door handyDART and Taxi Saver coupon program.  Both are available to you, to aid in expanding your ability to maintain independence and travel in the community.

 

To avoid delay in processing your application, please complete the following form.  After we have  received your completed form our handyDART staff will contact you to discuss your application and assist you regarding your handyDART and/or other travel options.

 

It is important that all parts of this application are completed.  Incomplete forms may delay processing your application.

 

If you have any questions, please call 855-0080.

 

Part 1 - General Information

 

PLEASE PRINT

 

Last Name

 

First Name

 

Initial

 

Address

 

Apt. #

 

 

 

City

 

Province

 

Postal Code

 

Telephone

 

 

 

 

 

Date of Birth

month/day/year

___/___/___

Female

Male

 

 

IF A SPOKESPERSON OR ADVOCATE IS APPLYING FOR YOU PLEASE HAVE THEM PROVIDE  

NAME:                                                                                  

ADDRESS:                                                                           

TELEPHONE:                                                                     

Please provide the following information which may be necessary for handyDART:

Medical/Therapist

 

Telephone:

 

Emergency Contact Name:

 

Relationship:

 

Daytime Phone:

 

Evening Phone:

 

 

Can you be left alone at your residence?

YES

 

NO

 

 

NOTE:  If no, the person you have identified as the emergency contact will be called in the event no one is available to receive you at your residence or in the event of an emergency.
Part 2 - Disability Information

1.       What is your disability which prevents you from using the regular bus? (check all that apply)

None

 

 

Bone/Joint

 

 

 

 

 

 

Brain/Nerves/Muscle

 

 

Development or Mental Condition

 

 

 

 

 

 

Respiratory Condition

 

 

Heart/Circulatory Condition

 

 

 

 

 

 

Vision/Hearing/Speech Condition

 

 

Other

 

 

Please describe your disability in detail.                                                                                                                

 

                                                                                                                                                                                       

 

                                                                                                                                                                                       

 

                                                                                                                                                                                       

 

2.       Please explain how your disability prevents you from using regular buses.                                                   

 

                                                                                                                                                                                       

 

                                                                                                                                                                                       

 

                                                                                                                                                                                       

 

3.     Is your disability

 

Permanent (life long)

Yes

 

No

 

 

 

 

 

 

 

Episodic (Please explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Temporary until:

 

 

 

 

 

4.     Do you use any of the following to help you get where you need to go? (please check all that apply)

 

none

 

 

power wheelchair

 

 

 

 

 

 

 

 

crutches

 

 

scooter

 

 

 

 

 

 

 

 

walker

 

 

white cane

 

 

 

 

 

 

 

 

manual wheelchair

 

 

service animal

 

 

 

 

 

 

 

 

cane

 

 

other

 

 

 

5.     Do you use the Central Fraser Valley Transit System’s accessible fixed route service?

 

Yes

 

How many days per month

 

 

 

 

 

 

 

No

 

I don’t ride because

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part 3 - Applicant Signature

 

I hereby declare that I have a disability that is sufficiently severe that I am unable without assistance to use the regular transit service.  I consent to the disclosure of personal information (including medical information) by my medical practitioner, to the Central Fraser Valley Custom Transit Operator for the purpose of determining my eligibility for the handyDART and Taxi Saver service.  I understand that the Operator has the right to review my application from time to time and can revoke my handyDART registration if they determine that I am no longer eligible for handyDART service.  I understand and agree to advise handyDART without delay if, at a future date, I am able to use regular accessible transit service.

 

REMINDER: WE ARE REQUESTING INFORMATION ONLY.  THE ACTUAL DETERMINATION OF ELIGIBILITY IS THE RESPONSIBILITY OF THIS OFFICE.

 

SIGNATURE OF APPLICANT:

 

                                                                                                                                               

 

NAME:                                                                                                                                  

 

DATE:                                                                                                                                   

 

 

 

 

Please send completed application to:

 

 

Central Fraser Valley Custom Transit

HandyDART

#19 - 3275 McCallum Road

Abbotsford, BC  V2S 4N3

 

 

 

 

 

 

 

 

 

 

 

CENTRAL FRASER VALLEY TRANSIT SYSTEM APPLICANT INFORMATION

 

 

Name of Applicant:                                                                                                                                   

Address:                                                                                                                                                    

City:                                                            Province:                   Postal Code:                                        

Telephone:                                                                   Date of Birth:                                                       

 

Do you use a wheelchair?    Yes            No                  Three-wheel scooter?          Yes           No         

 

Do you use:   Walker              Crutches               Other mobility aid (specify)                                         

 

I, ________________________________________________________ (name of applicant),

hereby declare that I have a disability that is sufficiently severe that I am physically unable without assistance to use conventional transit service.  I authorize BC Transit and the handyDART operating company to determine my eligibility for handyDART service and, if necessary, to consult with me and/or the medical practitioner named on the reverse.  I consent to the disclosure of personal information (including medical information) by my medical practitioner, to BC Transit and the handyDART operating company for the purpose of determining my eligibility for the handyDART service.  I understand that BC Transit and the handyDART operating company have the right to review my application from time to time and can revoke my handyDART registration if they determine that I am no longer eligible for handyDART service.  I understand and agree to advise BC Transit without delay if, at a future date, I am able to use conventional transit service.

 

SIGNATURE OF APPLICANT:                                    SIGNATURE OF WITNESS:

 

 

 

 

NAME:

 

 

NAME:

 

 

 

 

 

 

DATE:

 

 

DATE:

 

 

 

 

 

 

 

 

 

 

 

 

Reverse side of form must be completed by applicant’s medical practitioner (i.e. physician). 

Please return completed form to:                             

 

 

 

 

 


 

 

 

CENTRAL FRASER VALLEY CUSTOM TRANSIT SYSTEM

 

 

Custom Transit (handyDART) is a special door-to-door transit service for persons with disabilities who are unable to use the regular fixed-route transit system without assistance.  B.C. Transit Regulation 30/91 under the British Columbia Transit Act designates the following persons as eligible for handyDART service:

 

“(a)      persons with disabilities[1] as defined under the Disability Benefits Program; and

 

 (b)       persons who have a disability, either permanent or temporary, confirmed by a medical practitioner that is sufficiently severe that the person is physically unable without assistance to use conventional transit service.

 

 

 

 

VERIFICATION OF ELIGIBILITY FOR handyDART/HandyPass BY APPLICANT’S MEDICAL PRACTITIONER

 

Medical Practitioner’s Name:                                                                                                                   

Position:                                                                                                                                                    

Address:                                                                                     City:                                                       Province: ____________   Postal Code: ______________   Telephone: _________________         __

 

I hereby verify that                                                                    (name of applicant)  has a disability that is sufficiently severe that he/she is physically unable without assistance to use conventional transit service.  The applicant’s disability renders the applicant physically unable without assistance to use conventional transit service for the following reason(s): ___________________________                _.

 

 

 

Nature of Disability:                                                                                                                                 

 

Type of Disability:          Permanent:  __________

 

Temporary: __________ Date on which recovery is expected: _____   _____.

 

 

_______________________________________                ________________________          _

Signature of Medical Practitioner (i.e., physician)                                               Date Signed

 



[1] Person with a disability means a person

(a)     who is 18 years of age or older

(b)    who, as a direct result of a severe mental or physical impairment,

(i)      requires extensive assistance or supervision in order to perform daily living tasks within a reasonable time, or 

(ii)     (ii) requires unusual and continuous monthly expenditures for transportation or for special diets or for other unusual but extensive and continuous needs, and

(c)      who has confirmation from a medical practitioner that the impairment referred to in paragraph (b) exists and

(i)      is likely to continue for at least 2 years

(ii)     is likely to continue for at least one year and is likely to recur.