Transportation Eligibility Online Application

NAME:
ADDRESS:
CITY,  ST.  ZIP;
EMAIL ADDRESS: 
SOCIAL SECURITY # WILL BE REQUIRED
DATE OF BIRTH;
PHONE NUMBER:
EMERGENCY CONTACT:
EMERGENCY CONTACT ADDRESS:


Eligibility

Transportation Eligibility is limited to individuals who have little or no access to transportation due to income (150% of the Federal Poverty Level); are over the age of 60; or have a disability that prevents the individual from driving. You must include a copy of the selected documentation to be approved for service. Completing this application does not automatically certify you for service. Applicants may be required to undergo a functional assessment to assist FCPT in determining your level of eligibility.

Please include a copy of ALL supporting documentation for each selected section to confirm eligibility:

I am unable to transport myself or purchase transportation because I am:
Low Income – Combined Annual Household Income: $
                  DCF Benefit .    SSI Statement or Proof of Income .     Medicaid Card .    Housing Benefit
                   Unemployment Compensation .    Other:
Over the age of 60 (ID WILL BE REQUIRED)
Disabled – Unable to operate a vehicle (MEDICAL DISCLOSURE OR DOCTOR VERIFICATION WILL BE REQUIRED)
Do you own a vehicle?YES .         NO
Does anyone in your household own a vehicle? YES .         NO
Do you have relatives/friends that can transport you?YES .         NO 
Do you live in a facility that provides transportation?YES .          NO
Please provide the name of the facility you reside, if applicable:
Do you have weekly scheduled appointments?YES .         NO
Which days?  T  W  TH F  
TIME:

Mobility Aids

Please select any and all special needs or mobility aids you may require:
Manual Wheelchair  Powered Wheelchair Powered Scooter Walker Cane
Personal Care Attendant (PCA) Respirator  Service Animal Child Car Seat  White Cane
Do you have any other needs/conditions that we need to be aware of in order to transport you safely?

Certification & Acknowledgement

By submiting this online form, I understand and affirm that the information provided in this application is true and correct to the best of my knowledge. I understand that providing false or misleading statements constitute a felony under the laws of the State of Florida. I have read and understand all of the rules and policies that I am responsible for in the FCPT Rider’s Guide I was provided with this application.

Flagler County Public Transportation collects your social security number for verification purposes only. Social Security numbers are a unique identifier and may be used for search purposes. Social Security numbers will never be shared.

Please include a copy of ALL supporting documentation for each selected section to confirm eligibility: 
(supporting documents can be emailed to fcpt@flaglercounty.org)

PLEASE SUBMIT SUPPORTING DOCUMENTS HERE;