DIAL-A-RIDE APPLICATION

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IF YOU ARE UNDER 60 YEARS OF AGE YOU MUST HAVE YOUR PHYSICIAN COMPLETE THE PHYSICIAN’S

VERIFICATION ON THE 2ND PAGE OF THIS FORM OR PROVIDE US WITH PROOF OF DISABILITY. PLEASE

SEE DIAL-A-RIDE REQUIREMENTS ATTACHED HERETO AND MADE A PART HEREOF.

Submit the following to process your DIAL-A-RIDE membership:
1) Completed Application
2) Copy of identification with your date of birth and residential address
3) Physician’s Verification (only if under 60 years old-or you do not have qualifying proof of disability)
APPLICANT INFORMATION
Name:
Date of birth: / Phone: / P.O. Box:
Current address:
City: / State: / ZIP Code:
Male Female (Please circle) / Disabled: Yes No (Please circle) / Legally Blind: Yes No (Please circle)

EMERGENCY CONTACT (Optional)

Primary Contact:
Type of Relationship: / Phone:
Secondary Contact:
Type of Relationship: / Phone:
Additional Comments:

ADDITIONAL INFORMATION

I use the following: Walker Manual wheelchair Electric wheelchair Service Animal Other (Circle all that apply)
Do you require a self-provided escort? Always Sometimes Not Required (Please circle)
Additional Comments:

SIGNATURE

I assume full responsibility for and release the City of Avalon, Catalina Transportation Services as well as its drivers from any
Liability for my safety and well-being before I board and after I exit the DIAL-A-RIDE vehicle.
Signature of applicant: / Date:
For Administration Purposes Only
Date Mailed:
Processed By:
Comments:
This form is provided by Catalina Transportation Services

PHYSICIAN’S VERIFICATION

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Part ii of application (only for disabled applicants under 60 years old)

This section must be completed by an authorized California Physician
ELIGIBILITY EVALUATION
Applicant’s Name:
Indicate the disability that would require the applicant to be eligible for Dial-A-Ride (
Other (Please Explain):

duration and degree of disability

The patient’s disability is: Permanent Temporary (Please circle)
If temporary, please indicate the length of disability: (Please circle)
2 months 4 months 6 months (*After 6 months, physician’s re-verification is required)
Does the applicant require a self-provided escort? (Please circle) Always Sometimes Not Required

physician’s information:

Name of certifying Physician:
Physician’s Address:
Physician’s Telephone No.: Certifying Physician’s Medical License No.:

SIGNATURE

I ______(printed name of physician) certify that the individual patient/applicant named above meets the definition of disability and that all of the statements made above and any attached information are true and correct. I understand that submitting and/or attesting to any false information on behalf of an individual applicant could result in the revocation of any falsely acquired certification of the above individual applicant and/or could result in legal action against the individual applicant and/or physician in accordance with applicable laws and penal codes.
Signature of Certifying Physician: / Date:
For Administration Purposes Only
Date Mailed:
Processed By:
Comments:
This form is provided by Catalina Transportation Services

Catalina Transportation Services*P.O. Box 2141*228 Metropole Avenue*Avalon*CA*90704

Telephone: 310-510-0342 Fax: 310-510-1193