PWD PIKE COUNTY TRANSPORTATION SHARED RIDE APPLICATION FORM

PIKE COUNTY TRANSPORTATION PERSONS WITH DISABILITIES (PWD) APPLICATION FORM

For Residents Applying for the Persons with Disabilities (PWD) Program
Eligibility and Registration Form
Transportation for Persons with Disabilities (PWD) Program

Reduced fare transportation may be available to you if you are a person with a disability and you are between the ages of 18 and 64

If you would like to apply for this program, please complete this form and return the WRITTEN VERIFICATION OF DISABILITY FORM (attached). You may upload the form or emil it to PCT@pikep.org

Once your application is received, it will be reviewed and you will be notified of your eligibility status within 15 business days.

Note: The information provided in this application regarding your disability will be used to determine your eligibility for reduced fare transportation services under the PWD program. Other information within the form will be used for data collection purposes to determine your eligibility for any additional transportation programs and to provide you with the appropriate type of service. This information will be kept confidential and used only by professionals involved in evaluating your eligibility and assessing the program for future recommendations.
SECTION A: APPLICANT INFORMATION
Full Name *

First NameLast Name
Date of Birth *

MonthDayYear
Date
Social Security Number:*
Must include to check for dual eligibility
Physical Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Is your Mailing Address different from your Physical Address? *
Mailing Address *

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you have State Insurance? *
Includes Medicaid, Medicare, ACCESS Medical
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone:*
Please enter a valid phone number.Format: (000) 000-0000.
SECTION B: Eligibility Verification
Definition of Disability under the Americans with Disability Act.

Eligibility for this program is based on disability as defined by the Americans with Disability Act. (ADA). According to the ADA, “Disability means, with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities of such individual; a record of such an impairment or being regarded as having such an impairment.” “Major life activities” means functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and work.”
YesNo
The passenger must have a disability as defined by the Americans with Disabilities Act (ADA). Disability must be verified using an acceptable proof-of-disability document:
- Behavioral Health/Developmental Disabilities (BH/DD) Program
- Bureau of Blindness and Visual Services
- Center for Independent Living
- Community Services Program for Persons with Physical Disabilities
- Functional Assessment – performed for ADA eligibility
- Individual Support Plan (ISP)
- Office of Vocational Rehabilitation
- PA Attendant Care Program
- Physician
- Registered Nurse
- Registered Physical/Occupational Therapist
- Social Worker
- Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)
- United Cerebral Palsy
Please download, complete, and return the PwD Verification Form Here: WRITTEN VERIFICATION OF DISABILITY FORM

The applcation will not considered compelete until this form is returned and compelted. You may upload the Verification beow at the time of applcations or email it to PCT@Pikepa.org or fax it to 570-296-3409
PwD Verification Form:

Cancelof
PwD Acceptable Proof of Age Documents

Please provide one of the following documents that includes your date of birth:
- Armed Forces Discharge Papers
- Birth Certificate
- Enhanced Tribal Card or Native American Tribal Photo Identification Card
- EVS Printout (MATP)
- Form I-94 - Immigration Record from Customs and Border Protection
- Naturalization Papers
- Passport
- Pennsylvania Department of Corrections Inmate Identification Card
- Resident Alien Card
- Statement of Age (issued by the Railroad Retirement Board)
- Statement of Age (issued by the U.S. Social Security Administration)
- State-Issued Photo ID Card
- U.S. Department of Defense ID
- U.S. Driver’s License
- Veteran Health ID Card
Ensure your document is current and clearly displays your date of birth to verify eligibility. For more information or assistance, please contact our support team.
Upload proof of age:*

Cancelof
SECTION C: TRANSPORTATION NEEDS
Is your Disability Permanent? *
Standard definition of a permanent disability is one that lasts 12 months or longer.
If NO, please enter (Start date & end date)*
Do you require an escort to travel with you?*
An escort is necessary when a person is NOT able to board and disembark independently and/ or NEEDS assistance during the trip).
Describe your need for assistance if applicable:*
Mobility DisabilityVision DisabilityHearing DisabilityCognitive DisabilityMental DisabilityOther Please Specify:
Manual WheelchairVision DisabilityMotorized ScooterCrutchesCaneWalkerNoneOther Please Specify:
Please provide directions to your home: (Include: side of the street, color of house and landmarks)*
SECTION D: AVOIDING DUPLICATION OF TRANSPORTATION SERVICES

Transportation services provided under the PWD program are NOT to be provided in place of any current transportation services that you already receive.
Senior Citizens Shared-Ride Transportation ProgramMedical Assistance Transportation ProgramNoneI Do Not Know
SECTION C: Release of Information and Your Certification of Application
YesNo
Your Signature (or signature of your representative) *
YesNo
Your Signature (or signature of your representative) *
YesNo
Your Signature (or signature of your representative) *
Name of person who completed this form (self or representative):*

First NameLast Name
Should be Empty:

PIKE COUNTY TRANSPORTATION PERSONS WITH DISABILITIES (PWD) APPLICATION FORM

SECTION A: APPLICANT INFORMATION

SECTION B: Eligibility Verification

SECTION C: TRANSPORTATION NEEDS

SECTION D: AVOIDING DUPLICATION OF TRANSPORTATION SERVICES

SECTION C: Release of Information and Your Certification of Application