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Demand Response Service Application ADA / Dial‐A‐Ride / Flex

The information that you provide on this application is intended for the sole purpose of establishing eligibility for transportation service. Dutchess County will not release this information, except to the sponsoring Dial-A-Ride town for other purposes, without your written permission.

* Indicates Required Field

  1. Please check the service(s) for which you are applying:(Check all that apply)
      ADA/Special Privilege Transit Card

  1. *

  1. *


  1. *

  1. Please check the reason(s) you are requesting transportation. It is significantly difficult for me to:
       Walk more than 200 feet
       Stand outside more than 10 minutes
       Negotiate a flight of stairs
       Get on or off a standard bus
       Stand on a moving bus
       Read information due to visual impairment
       Hear announcements made by the bus driver
       Other, please explain
    Maximum number of characters: 1,000

  1. Do you use any of the following aides: (Check all that apply)
       Service Animal
       Other, please explain
    Maximum number of characters: 1,000

  1. Do you travel with a personal care attendant:

  1. Do you have special needs the dispatcher should be aware of when scheduling your trips:
    If yes, please explain: Maximum number of characters: 1,000

  1. Please provide the following information for someone we may contact in case of an emergency: *

Dutchess County requests a reference who may be contacted to verify your eligibility for the ADA Complementary Paratransit Service Program. This reference may be a doctor or other health care professional.

  1. Are you a client of a community service agency:
    If yes, which agency (Please enter Address and Telephone Number): Maximum number of characters: 1,000

  1. If service applied for in Question 1. is ADA/Special Privilege Transit Card, Please provide the name and contact information of a physician or other health care professional as a reference:

  1. I state that the information provided in this application is true and complete to the best of my knowledge and agree to release it to Dutchess County for the purpose of establishing my eligibility for transportation service. I also understand that the professional reference named above may be contacted to validate my eligibility.
       Please check this box after reading the statement above. *

For further information call: 845-473-8424

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