San Francisco Paratransit Broker

68 12th Street

San Francisco, CA 94103

Intake & Application Department (415) 351-7050

ADHC & ADC GROUP VAN RECERTIFICATION FORM

(This form may be used only by previously ADA-certified clients registered as permanent and full eligiblefor SF Paratransit)

The following questions will help us in updating your eligibility for SF Paratransit. Please complete all questions or the application will be considered incomplete. An incomplete application will be returned, and will delay the ongoing eligibility re-determination process. Please print or type.

Personal/Contact Information

Name(first, middle, last): ADA Paratransit ID #:

______

Name of Adult Day Health Center or Adult Day CareProgram currently attending

______

Home Address: ______Apt. #: ______

City: ______Zip: ______

Mailing Address(if different from home):

______Apt. #: ______

City: ______Zip: ______

Daytime Phone: (_____) ______TDD/TTY: (____) ______

Evening Phone: (_____) ______

Birth Date: ____/____/____ Female Male

Primary Language(please check): English Other (specify) ______

In case of emergency, whom should we contact?

Name: ______Day Phone: (____) ______

Relationship: ______Eve. Phone: (____) ______

Please answer the following questions in detail – your specific answers to the questions will help us in determining your eligibility.
Tell Us About Your Current Condition

1.Has your condition changed since being certified for the Group Van Program?

YesNo

If yes, explain the changes that have occurred. (You may still be entitled

to ADA Paratransit Services).

______

______

______

2.Do you use any of the following mobility aids?

Cane Power Wheelchair Communication Devices
White CaneService Animal Walker

Power ScooterCrutches Manual Wheelchair

Leg BracesPortable Oxygen Tank

Other:______

Applicant’s signature: ______Date: ______

If this form has been completed by someone other than the applicant,
please provide the following:

1. Should this rider be designated as “attendant required”(ATR)?

YesNo

Signature of Social Worker or Program Director

______

Print name: ______Phone # : ______

Email: ______