Dial-A-Ride Application

PLEASE READ BEFORE FILLING OUT THIS APPLICATION

The objective of Easy Lift Transportation is to provide a safe, efficient, and affordable paratransit service to south Santa Barbara County. In order to achieve this goal there are rules and regulations we all need to adhere to. The purpose is to make everything run as smoothly as possible. We do our best to accommodate everyone and provide as many rides as possible though the demand continues to grow. However, WE ARE NOT A TAXI SERVICE. We are a special service for people with special needs who cannot use the MTD city bus system. The service requires team work and cooperation, and we must work hand in hand with our passengers. Together with your patience and support we will achieve our goals.

Who can use Easy Lift’s paratransit service?

The law states the following factors must be considered when determining eligibility:
- Does the disability prevent him or her from getting to and from the closest bus stop?
- Can the individual use their bus pass or buy a ticket without help?
- Can the individual recognize their destination and get off the bus?
- If a bus trip involves transfers, would the individual know when to get off and where to catch the next bus?
- Is the individual’s ability to use the MTD bus affected by environmental/ architectural barriers that block their path of travel? (i.e. steep hills, no sidewalks, dead end streets, lack of any audio signal which indicates it is safe to cross the street, etc.)
What constitutes a disability?

The ADA defines a disability as a physical, visual, or mental impairment that substantially limits one or more of the major life activities of an individual. Major life activities include caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.

How do I apply?

If you think you are eligible, fill out the Application for ADA Paratransit Eligibility enclosed and mail it back to us. You are required to fill out an application and describe your disability or condition that prevents you from using the MTD fixed-route system. Your disability or condition must meet ADA requirements for certification. When Easy Lift receives your completed application it will be evaluated and eligibility will be determined based on your functional ability to use MTD. The reviewer may request additional information, such as a phone or in-person interview with you, or written medical/professional verification.

Instructions for Completing this Application

All information will remain confidential.

All questions on this application must be answered in full. You may fill out this form yourself or you can get help from anyone familiar with you and your condition.

Once the application is complete, please return it to:

Easy Lift Transportation
53 Cass Place, Suite D
Santa Barbara, CA 93117

Within 21 days of receiving your completed application, you will be notified as to the status of your application.

If you do not receive notification of our decision within 21 days of our receipt of your application, you may ask for and receive paratransit services until a decision is made.

If you are found eligible for ADA¹ services, you will promptly receive information on how to use our services, and if requested, you will be given an orientation on how to use Easy Lift’s services.

If you are found ineligible for our service and you disagree with our recommendation, you may appeal the decision. Information on the appeals process will be sent to you, upon request.

If you have any questions about this application, please call our Eligibility Intake Coordinator at (805)845-8963.

¹ Americans with Disabilities Act of 1990

Name*
First Last
Date of Birth*
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Complex
If this is a "Gated Community", please provide gate code:
Mailing address if different:
Street Address Address Line 2 City State ZIP Code
Email
Day Phone #*
Cell Phone #
Best Way to Contact You*
- Please only contact me via email
- Please only contact me via snail mail
- I do not wish to receive follow up emails
How did you hear about Easy Lift?*
Emergency Contact
Please provide the name of a local friend or relative to call in case of emergency.
Name*
First Last
Relationship*
Email
Day Phone #*
Cell Phone #

Section 2 - Information About Your Functional Abilities
Please answer the following questions in detail - your specific answers to the questions will help us in determining your eligibility. All answers requiring explanation must be complete.
WITHOUT the help of someone else, can you...
1. Ask for and understand written or spoken instructions?*
2. Cross the street?*
3. Stand for 15 minutes if there is no place to sit?*
4. Step on and off a sidewalk from a curb?*
5. Find your own way to the bus stop if someone shows you the way once or twice?*
6. Walk up and down three steps if there is a handrail?*
7. Walk up and down a flight of stairs if there is a handrail?*
8. Stand on a moving bus holding onto a handrail?*
9. Transfer from one fixed route bus to another?*
10. Are there any walls barriers or obstacles that block your path to the nearest bus stop?*
11. Under the best of conditions, what is the FURTHEST you can walk outdoors (or travel using your mobility aid) without the help of another person?*
- Less than 1 block
- 1 block
- 2 blocks (1/4 mile)
- 4 blocks (1/2 mile)
- 6 blocks (3/4 mile)
- More than 6 blocks
- I cannot travel outdoors alone at all
12. Is there anything else you want to tell us about your disability or health condition that might help us better understand your travel abilities and limitations?

Section 4 - Mobility Training
1. Have you ever had any training or instruction to learn how to use public transportation?*
- Yes
- No
Please Explain
2. Free Travel and Mobility Training is personal (one-on-one) instruction that teaches an individual how to use MTD fixed-route buses. Would you like to have an Easy Lift Mobility Coordinator contact you?*
- Yes
- No

Section 5 - Certification of Applicant
- I hereby certify that, to the best of my knowledge, information given in this application is correct.
- I understand that this application will not be processed if it is not complete.
- I understand that the results of the review will be based on my ability to use regular bus transport and may require additional information from me, such as a phone or personal interview or additional consultation with my physician or other professional.
- I agree to notify Easy Lift Transportation, Inc. if I no longer need to use the ADA Paratransit Service.
- I further understand that my ADA Paratransit Eligibility Approval may be reassessed or revoked at any time, if eligibility was granted based on information which is found to be inaccurate, false, or which has changed significantly enough to warrant a change in category.
Electronic Signature of Applicant*
Date*
If someone other than the applicant completed this application, their information must be provided.
Name of person completing or assisting with the application
Relationship to Applicant
Signature of Assistant
Date
Daytime Phone
Evening Phone

Section 6 - Professional Medical Verification
In order for Easy Lift to evaluate your request for eligibility, it may be helpful for us to contact a professional who is familiar with your health condition or disability and functional abilities and limitations. Please list one professional who we can contact if we need additional information.

Examples of qualified professionals include: Physician (M.D. or D.O.), physical therapist, occupational therapist, orientation and mobility instructor, independent living specialist, rehabilitation specialist, social worker, registered nurse, ophthalmologist, psychiatrist, psychologist, or case manager.
1. Name of Professional
Type of Professional
Professional's Agency
Address
Street Address City State ZIP Code
Authorization for Release of Information
I authorize the professional (s) listed above to release to Easy Lift Inc. the information about my disability or health condition and it’s effect on my ability to travel on the MTD. I understand that I may revoke this authorization at any time. Unless earlier revoked, this form will permit the professional listed to release the information described up to 90 days from the date below.
Electronic Signature*

(Signature of Applicant, Responsible Party, or Legal Guardian)
Relationship to Applicant
Daytime Phone*
Evening Phone

Dial-A-Ride

ADA Paratransit Eligibility Application

Step 1 of 8 - Instructions

PLEASE READ BEFORE FILLING OUT THIS APPLICATION

Who can use Easy Lift’s paratransit service?

What constitutes a disability?

How do I apply?

Instructions for Completing this Application

Emergency Contact

Section 1 - Continued

Section 2 - Information About Your Functional Abilities

Section 3 - Information about your abilities to use Fixed Route

Your Current Travel

Section 4 - Mobility Training

Section 5 - Certification of Applicant

Section 6 - Professional Medical Verification

Authorization for Release of Information