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

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

2. Name: *
   
   

3. Street Address:
   
   City/Town/Village: Select City/Town/Village City of Beacon City of Poughkeepsie Town of Amenia Town of Beekman Town of Clinton Town of Dover Town of East Fishkill Town of Fishkill Town of Hyde Park Town of LaGrange Town of Milan Town of North East Town of Pawling Town of Pine Plains Town of Pleasant Valley Town of Poughkeepsie Town of Red Hook Town of Rhinebeck Town of Stanford Town of Union Vale Town of Wappinger Town of Washington Village of Fishkill Village of Millbrook Village of Millerton Village of Pawling Village of Red Hook Village of Rhinebeck Village of Tivoli Village of Wappingers Falls
   
   
   Zip Code: Select Zip Code 12501 12504 12506 12507 12508 12510 12511 12512 12514 12522 12524 12527 12531 12533 12537 12538 12540 12545 12546 12564 12567 12569 12570 12571 12572 12574 12578 12580 12581 12582 12583 12585 12590 12592 12594 12601 12602 12603 12604
   
   
   

4. Telephone Number: *
   
   

5. Date of Birth: Select Month January February March April May June July August September October November December     Select Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31     Select Year 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1949 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

6. Municipality of Residence: * Select City/Town/Village City of Beacon City of Poughkeepsie Town of Amenia Town of Beekman Town of Clinton Town of Dover Town of East Fishkill Town of Fishkill Town of Hyde Park Town of LaGrange Town of Milan Town of North East Town of Pawling Town of Pine Plains Town of Pleasant Valley Town of Poughkeepsie Town of Red Hook Town of Rhinebeck Town of Stanford Town of Union Vale Town of Wappinger Town of Washington Village of Fishkill Village of Millbrook Village of Millerton Village of Pawling Village of Red Hook Village of Rhinebeck Village of Tivoli Village of Wappingers Falls

7. Nearest Intersection:
   
   

8. 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 a visual impairment
     Hear announcements made by the bus driver
     Other, please explain
   Maximum number of characters: 1,000
   
   

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

10. Together, how much do you and your mobility device weigh:
    
    

11. Do you travel with a personal care attendant:

    Yes

    No

12. Do you have special needs the dispatcher should be aware of when scheduling your trips:

    Yes

    No

    If yes, please explain: Maximum number of characters: 1,000

13. Please provide the following information for someone we may contact in case of an emergency: *
    
    Name:
    
    Street Address:
    
    City:
    
    State: Select State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
    
    
    Zip Code:
    
    Telephone Number:
    
    Relationship to Applicant:
    
    

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.

14. Are you a client of a community service agency:

    Yes

    No

    If yes, which agency (Please enter Address and Telephone Number): Maximum number of characters: 1,000

15. 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
    
    You checked ADA/Special Privilege Transit Card for Question 1, please provide the name and contact information of a physician or other health care professional for Question 15.
    Name:
    
    Street Address:
    
    City:
    
    State: Select State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
    
    
    Zip Code:
    
    Telephone Number:
    
    

16. 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