Parts A and B: Applications for SunDial Paratransit Service

Date

MonthDayYear
Date
Application for SunDial Paratransit Service
Informational Sheet
¿Qué es SunDial?

SunDial es un servicio de viaje compartido de origen a destino provisto de acuerdo con la Ley de Estadounidenses con Discapacidades (ADA, por sus siglas en inglés). Forma parte del sistema de transporte público de SunLine y funciona junto con el servicio fijo de autobuses SunBus.

SunDial está disponible para pasajeros cuyas limitaciones funcionales les impiden usar de manera independiente el SunBus, aun cuando este es totalmente accesible bajo la ADA.

Tenga en cuenta que SunDial es transporte público y no un servicio médico de transporte. SunDial no funciona como un servicio privado; otros pasajeros también estarán a bordo y los viajes pueden incluir paradas adicionales para recoger o dejar a otros usuarios.

Acerca de SunBus
SunBus es el sistema de autobuses de ruta fija disponible para todos los pasajeros, incluyendo a aquellos con discapacidades. Los autobuses incluyen:
- Entrada baja con sistema de inclinación (“kneeling”)
- Rampas o elevadores
- Anuncios de audio
- Asientos prioritarios y señalización mejorada
- Pasamanos
Estas características permiten que muchos pasajeros con discapacidades viajen de manera segura e independiente.

El paratránsito SunDial es:
- Parte del sistema de transporte público de SunLine.
- Un servicio de viaje compartido de origen a destino provisto bajo la ADA.
- Comparable al SunBus de ruta fija en tiempo de viaje, área de servicio y desempeño.
- Limitado al área de servicio que cubre hasta ¾ de milla de cualquier ruta regular de SunBus.
- Un servicio basado en reservaciones donde los viajes pueden incluir múltiples paradas para otros pasajeros.
El paratránsito SunDial no es:
- Un taxi privado.
- Un servicio médico de transporte.
- Un servicio de transporte que garantice viajes directos sin paradas.
- Un servicio de transporte que permita llevar bolsas o paquetes ilimitados.
Ejemplos de situaciones que por sí solas no califican para el paratránsito SunDial:
Un diagnóstico médico o múltiples diagnósticos.
- La edad.
- La distancia de la vivienda a la parada de autobús.
- Sentirse inseguro.
- No conducir.
- Inconveniencia o incomodidad.
Cómo solicitar el servicio Electrónicamente

Paso 1 – Complete la Parte A (Información del pasajero)

Llene toda la Parte A en línea. Responda cada pregunta completamente.

Paso 2 – Complete la Parte B (Certificación del proveedor de salud)
- Si usted es un proveedor de salud autorizado, puede completar la Parte B en línea.
- Si no es un proveedor de salud, imprima la Parte B y entréguela a su proveedor.
Paso 3 – Envíe ambas partes juntas
- Cargue la Parte B en esta solicitud (escaneo claro o fotografía).
- Las solicitudes no serán procesadas a menos que la Parte A y la Parte B se presenten juntas.
Paso 4 – Revise su correo electrónico

Revise su correo electrónico para actualizaciones. Si se requieren correcciones, recibirá un enlace para hacer cambios y volver a enviar la solicitud.

Recordatorios importantes
- Use esta solicitud solo para envío en línea.
- ⚠️ Este formulario en línea no puede ser enviado por correo.
- Si desea presentar su solicitud por correo regular, descargue la versión en PDF disponible en el sitio web de SunLine.
- Las páginas faltantes o respuestas incompletas retrasarán su solicitud. Las solicitudes incompletas serán devueltas con instrucciones para su reenvío.
- No envíe la Parte A sin la Parte B, ni la Parte B sin la Parte A. Ambas partes de la applicación deben presentarse juntas para empezar el proceso.
What is SunDial?

SunDial is an origin-to-destination, shared-ride service provided in accordance with the Americans with Disabilities Act (ADA). It is part of SunLine’s public transportation system and operates alongside the fixed-route SunBus. SunDial is available to riders whose functional limitations prevent them from independently using the SunBus, even though SunBus is fully ADA accessible. Please note that SunDial is public transportation and not a medical transportation service.

About SunBus
SunBus is the fixed-route bus system available to all riders, including those with disabilities. Buses include:
- Low-floor entry with kneeling capability
- Ramps or lifts
- Audio announcements
- Priority seating and enhanced signage
- Handrails
These features allow many passangers with disabilities to travel safely and independetently.

SunDial Paratransit is:
- A part of SunLine’s public transportation system.
- An origin-to-destination, shared-ride service provided under the Americans with Disabilities Act (ADA).
- Comparable to SunLine’s fixed-route SunBus in travel time, service area, and performance.
- Limited to the service area that extends up to ¾ of a mile from any regular SunBus route.
- A reservation-based service where trips may include multiple stops for other riders.
SunDial Paratransit is not:
- A private taxi.
- A medical transportation service.
- A transportation service that guarantees direct, non-stop travel.
- A transportation service that allows unlimited bags or packages.
Examples of things that do not qualify on their own for SunDial Paratransit:
- A medical diagnosis or multiple diagnoses
- Age
- Distance from a bus stop
- Feeling unsafe
- Not driving
- Inconvenience or discomfort
How to Apply
Step 1 – Complete Part A (Rider Information)
Fill out all of Part A online. Answer every question completely.

Step 2 – Complete Part B (Health Care Provider Certification)
- If you are a licensed health care provider, you may complete Part B online.
- If you are not a health care provider, print Part B and take it to your provider.
Step 3 – Submit Both Parts Together
- Upload Part B into this application (clear scan or photo).
- Applications are not processed unless Part A and Part B are submitted together.
Step 4 – Check Email
Check your email for updates. If corrections are needed, you will get a link to make changes and resubmit.

Important Reminders
- Use this application for online submission only.
- ⚠️ This online form cannot be mailed.
- If you wish to apply by mail, download the PDF application on SunLine’s website.
- Missing pages or incomplete answers will delay your application. Incomplete applications will be returned with instructions for resubmission.
- Do not submit Part A without Part B, or Part B without Part A. Both must be together to start the process.
PART A: Applicant Information and Release

Personal Data
Name:*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
You can either select a date using the calendar icon or type it in manually (MM/DD/YYYY).
Home Phone:
Mobile Phone:
Other Phone:
Optional
Email Address:*
example@example.com - Using an email account will allow for a quicker response; however, it is the applicant's responsibility to regularly check their email for updates and notifications regarding their application.
Do you require TDD/TTY services?*

YesNo
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Gate Code:
Name of Apartment Complex/Community:
We request the apartment complex or community name to ensure accurate location details for transportation services, making it easier to identify pickup and drop-off locations within larger residential areas.
Is your home address the same as your mailing address?
Mailing Address:

Street Address

Street Address Line 2

CityState

Zip Code
Is this your first time applying or are you renewing your eligibility?*

New Application:Recertification:
SunDial ADA Number:
Exp. Date:

MonthDayYear
You can either select a date using the calendar icon or type it in manually (MM/DD/YYYY).
Please give us the name and phone number of a friend or relative we can call in case of emergency or if we are unable to reach you at your regular number:
Name

First NameLast Name
Phone:
Other Phone:
Relationship:
Application for SunDial Paratransit Service
Transit Usage
1. Do you currently use fixed-route (large public) buses*

YesNoSometimes
When was the last time you rode the fixed-route bus?

MonthDayYear
Date
I do not know.
How frequently do you ride the fixed-route bus?
Which fixed-route bus routes do you currently use?
2. Have you ever had travel training to learn how to travel around the community and/or on how to use fixed-route buses?*

YesNo
Would you like information about travel training to use the fixed-route*

YesNo
Disability/Health Condition Information
All questions must be answered.
3. Please describe the disability or health condition which prevents you from using fixed-route buses.
4. Is this a temporary disability or health condition?*

YesNo
If yes, how long you do expect it to prevent you from using fixed-route bus service?
Months
Application for SunDial Paratransit Service
5. Are you currently receiving any treatment?*

YesNo
If yes, check what treatment(s) apply to you

MedicationsPhysical TherapyChemotherapyRadiation TherapyDialysisPsychotherapyNon-weight Bearing ImmobilizationSurgeryRehabilitationWeight Bearing ImmobilizationConvalescenceOther
How long will you be receiving treatment?*

< 3 months3-6 months6-9 months9-12 months> 12 monthsUnknown duration
6. Have you had a recent fall which required medical attention?*

YesNo
If yes, what is your fall frequency per week?
If yes, did the fall occur while using mobility aid/device?*

YesNo
7. Do you live in an assisted living facility or nursing facility?*

YesNo
8. Do you ever need to bring someone with you to help you when you travel (a “personal care assistant” or “personal attendant”)?*

YesNo
9. Do you use any mobility aids or equipment? (check all that apply)*

Powered/Electric WheelchairManual WheelchairPower ScooterWalkerCaneCommunication BoardProsthesisPortable Oxygen In CartService AnimalWhite CanePortable Oxygen In BagCrutchesBraceNoneOther
Type of Brace:
If you use a wheelchair or scooter, what is the width and length?
Width:
Inches
Length:
Inches
If you use a wheelchair or scooter, what is the total weight of your mobility device when you are using it?
Weight:
If your wheelchair or scooter is larger than 30 inches wide, 48 inches long and 600 pounds when occupied, the SunLine paratransit vehicle may be unable to accommodate your trip.
Application for SunDial Paratransit Service
Transit Skills
Please read the following statements and check those which best describe your abilities to use fixed-route buses (SunBus) (check all that apply). At least one box needs to be checked.

I can get to and from bus stops if the distance is not too great.I can ride buses when I am feeling well. There are other times, when my disability or health condition worsens, that I cannot ride the buses.I have a disability or health condition that prevents me from riding the buses and if the weather is very hot or cold.My disability or health condition makes it impossible to travel when there is snow or ice on the ground.I can get to and from bus stops only if there are curb cuts and sidewalks.I can get to and from bus stops and light only if there are no hills.I have difficulty understanding or remembering all the things I would have to do to use the buses.I can use the buses if it is someplace that I go all of the time.I can never use buses by myself.I am not sure if I can use buses.I am not able to use buses for other reasons.
If you checked any of the above boxes, please explain:
Functional Skills

The following questions will give us more information about your functional abilities. Please select Always (A), Sometimes (S), or Never (N) in response to the following questions and provide an explanation.

Without the help of someone else can you:
Ask for and understand written or spoken instructions?*

AlwaysSometimesNever
If Sometimes or Never, please explain:
Cross the street?*

AlwaysSometimesNever
If Sometimes or Never, please explain:
Stand for 15 minutes if there is no place to sit?*

AlwaysSometimesNever
If Sometimes or Never, please explain:
Application for SunDial Paratransit Service
Step on and off a sidewalk from a curb?*

AlwaysSometimesNever
If Sometimes or Never, please explain:
Walk up and down three steps if there is a handrail?*

AlwaysSometimesNever
If Never, please explain:
Walk on uneven surfaces?*

AlwaysSometimesNever
If Never, please explain:
Stand on a moving bus if there is a handrail?*

AlwaysSometimesNever
If Never, please explain:
Transfer from one bus to another?*

AlwaysSometimesNever
If Never, please explain:
Under the best conditions, what is the farthest that you can travel outdoors (using your mobility aid if you use one without the help of another person?*

< 1 block1-4 blocks> 4 blocks
Please provide any other information about your disability or health condition that would help us better understand your travel abilities
Certification

I hereby certify that, to the best of my knowledge, information given in this application is correct. The purpose of this application is to determine if I am eligible to use paratransit services (SunDial), or if I can ride the SunLine fixed-route buses (SunBus). I understand that falsification of information could result in a loss of paratransit services as well as a penalty under the law. I agree to undergo an in-person assessment of my mobility abilities and limitations for the purpose of making a determination regarding my eligibility for paratransit service. I understand that intentionally providing false or misleading information or a refusal of an in-person assessment is grounds for a determination of ineligibility for SunDial services and benefits. I agree to notify SunLine if my condition changes, if I am using a new mobility device, or if I no longer need to use ADA paratransit service.
Applicant/Responsible Party Signature

Clear
Date

MonthDayYear
You can either select a date using the calendar icon or type it in manually (MM/DD/YYYY).
Application for SunDial Paratransit Service
Authorization for Release of Information
I First Name* Last Name* authorize my health care professional to release any and all information about my disability or health condition and its effect on my ability to travel on the SunLine fixed-route system (SunBus) (Part B). I understand that I may revoke this authorization at any time. I understand that SunLine Staff may contact the health care professional who completed the verification attached to this application, in order to confirm this information. I understand that all medical information will be kept strictly confidential.
Applicant/Responsible Party Signature:*

Clear
Date*

MonthDayYear
You can either select a date using the calendar icon or type it in manually (MM/DD/YYYY).
Did someone assist you in completing this application?

YesNo
If yes, please provide the following information:
Print Name
Agency (if applicable)
Relationship to Applicant
Address:

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Other Phone
Signature

Clear
Date

MonthDayYear
You can either select a date using the calendar icon or type it in manually (MM/DD/YYYY).
Are you a Health Care Provider?*
Do you have the Health Care Provider Certification (Part B - 4 pages)?*
Health Care Provider (Print Name)*
Institution/Facility/Agency name*
Health Care Provider Phone:*
Health Care Provider Email*
example@example.com
Please upload the Health Care Provider Certification (Part B - 4 pages) to start the process. Note: Part B needs to be completed by a health care provider. You can scan or take pictures of the Part B and upload them. Make sure the pictures have good quality/resolution. Parts A and B need to be together to start the process. *

⚠️ Important: Part B must be fully completed by a licensed healthcare provider. All four pages must be filled out, and every question answered. Missing information may delay your eligibility determination.
Cancelof
Please Download/print the Health Care Provider Certification (Part B) and take it to your Health Care Provider. You can save Part A and finish the process as soon as you have Part B. Have your health care provider mail the completed application to you. Once you receive it, you must mail both Parts A and B together or upload Part B in this application to complete the process. Do you know your health care provider's email address? If so, you can send Part A along with Part B to your health care provider. Parts A and B need to be together to start the process. IMPORTANT: Part A and B need to be together to start the process.
Part B: Health Care Provider Certification

All information must be filled out
Application for SunDial Paratransit Service
Informational Guide

What is SunDial?
SunDial is an origin-to-destination, shared-ride service provided in accordance with the Americans with Disabilities Act (ADA). It is part of SunLine’s public transportation system and operates alongside the fixed-route SunBus. SunDial is available to riders whose functional limitations prevent them from independently using the SunBus, even though SunBus is fully ADA accessible.

About SunBus
SunBus is the fixed-route bus system available to all riders, including those with disabilities. Buses include:
- Low-floor entry with kneeling capability
- Ramps or lifts
- Audio announcements
- Priority seating and enhanced signage
- Handrails
These features allow many passangers with disabilities to travel safely and independetently.

SunDial Paratransit is:
- A part of SunLine’s public transportation system.
- An origin-to-destination, shared-ride service provided under the Americans with Disabilities Act (ADA).
- Comparable to SunLine’s fixed-route SunBus in travel time, service area (¾ of a mile from a regular SunBus route), and performance.
- Limited to the service area that extends up to ¾ of a mile from any regular SunBus route.
- A reservation-based service where trips may include multiple stops for other riders.
SunDial Paratransit is not:
- A private taxi.
- A medical transportation service.
- A transportation service that guarantees direct, non-stop travel.
- A transportation service that allows unlimited bags or packages.
Examples of things that do not qualify on their own for SunDial Paratransit:
- A medical diagnosis or multiple diagnoses
- Age
- Distance from a bus stop
- Feeling unsafe
- Not driving
- Inconvenience or discomfort
How to Apply

Step 1 – Complete Part A (Rider Information)
Fill out all of Part A online. Answer every question completely.

Step 2 – Complete Part B (Health Care Provider Certification)

If you are a licensed health care provider, you may complete Part B online.
If you are not a health care provider, print Part B and take it to your provider.

Step 3 – Submit Both Parts Together

Upload Part B into this application (clear scan or photo).
Applications are not processed unless Part A and Part B are submitted together.

Step 4 – Check Email
Check your email for updates. If corrections are needed, you will get a link to make changes and resubmit.

Important Reminders
- Use this application for online submission only.
- ⚠️ This online form cannot be mailed.
- If you wish to apply by mail, download the PDF application on SunLine’s website.
- Missing pages or incomplete answers will delay your application. Incomplete applications will be returned with instructions for resubmission.
- Do not submit Part A without Part B, or Part B without Part A. Both must be together to start the process.
Part B: Health Care Provider Certification

All information must be filled out
Your patient First Name* Last Name* has requested eligibility for SunDial Paratransit Service. SunDial is an origin to destination, shared ride paratransit service for people whose disabilities or health conditions prevent them from riding the fixed route accessible transportation system all, or part of the time. As the applicant’s healthcare provider, you are uniquely qualified to clarify the applicant’s functional abilities and limitations to ride the SunLine fixed route bus system. In order to determine this applicant’s functional abilities, we require you, the healthcare provider, to complete and certify all of the following sections. Please detail how the applicant’s disability(ies) or health condition(s) impact his or her ability to board, navigate, and travel independently on the accessible fixed route system. Please be as specific as possible.
Health Care Provider (please print):*
Institution/Facility/Agency Name:*
License Number:*
State Issued:*
Specialization*
Address*

Street Address

Street Address Line 2

City/State/ZipState

Zip Code
Phone*
Email Address*
example@example.com - Using an email account will allow for a quicker response; however, it is the applicant's responsibility to regularly check their email for updates and notifications regarding their application.
Part B: Health Care Provider Certification
All information must be filled out.
1. Written diagnosis(es) and ICD-9CM and/or DSM Code(s)*
2. How long have you been treating the patient?*
3. When was the last time you saw the patient?*

MonthDayYear
Date
4. What is the expected duration of the disability?*

Short TermLong Term
Short Term: Conditions lasting at least 90 days but are likely to improve within one year
Long Term: Conditions with absolutely little expectation of improvement
5. In your opinion, does this applicant’s disability(ies) prevent him or her from independently using the accessible SunLine fixed route bus service (SunBus)?*

Yes (Answer question 6, if left blank, the application will be denied)No
6. If yes, explain how the disability or health condition impacts the applicant’s ability to travel independently on the accessible SunLine fixed route bus system (SunBus):*
(Answer question 6, if left blank, the application will be denied)
Part B: Health Care Provider Certification
All information must be filled out.
16. Do you use any mobility aids or equipment? (check all that apply)*

Powered/Electric WheelchairManual WheelchairPower ScooterWalkerCaneCommunication BoardProsthesisPortable Oxygen In CartService AnimalWhite CanePortable Oxygen In BagCrutchesBraceNoneOther
Type of Brace
8. If this applicant is currently on medication(s), will the side effects significantly reduce or hinder his/her ability to independently ride the accessible SunLine fixed route bus service?*

YesNoN/A
9. If you selected yes, please explain how the side effects would hinder their ability to use the accessible SunLine fixed route bus service
For questions 10-22, select Yes (Y), No (N), or Sometimes (S If you answer Yes or Sometimes to questions 10-22, elaborate on how it prevents the applicant from using accessible SunLine fixed route bus service:
10. Would temperature extremes affect this applicant’s ability to ride fixed route bus service?*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
11. Would ice and/or snow affect this applicant’s ability to ride fixed route bus service transit?*

YNS
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
12. Would poor air quality affect this applicant’s ability to ride fixed route busservice?*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
13. Does this applicant have any challenges with balance?*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
14. Does this applicant have any challenges with memory?*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
15. Does this applicant have any challenges with breathing?*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
16.Does this applicant have any challenges with strength and endurance?*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
Part B: Health Care Provider Certification
All information must be filled out.
17. Does this applicant have any challenges with ambulating on hills?*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
18. Are there any visual impairments that would affect this applicant’s ability to ride fixed route bus service?*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
19. Are there any hearing impairments that would affect this applicant’sability to ride fixed route bus service?*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
20. Does this applicant exhibit any inappropriate social behaviors? Y N SPlease Explain:*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
21. Do you have safety concerns for this applicant in using a bus bythemselves?*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
22. Does this applicant require a Personal Care Attendant when traveling?*

YESNOSOMETIMES
Please Explain:*
If you answered "Yes" or "Sometimes," please explain. If your answer is "No," write N/A.
23. In your medical opinion, what other factors related to the applicant’s disability(ies) affect his/her ability to ride the accessible SunLine fixed route service?*
The above information I have provided hereto is a fair representation of this applicant’s disability(ies) or health condition(s) and is true and correct under penalty of perjury according to the laws of the State of California. I understand the information provided will be used for the sole purpose of determining the applicant’s eligibility for paratransit service. I also agree that SunLine may contact me for clarification of any information I have provided and that I will reply with good faith. I understand the information contained herein is true and correct to the best of my knowledge and ability. Any falsification could result in the client’s loss of paratransit service. I certify that I am legally licensed and am currently treating:*
Patient's Name
Date*

Clear
Date*

MonthDayYear
You can either select a date using the calendar icon or type it in manually (MM/DD/YYYY).
Should be Empty:

Application for SunDial Paratransit Service

Informational Sheet

PART A: Applicant Information and Release

Application for SunDial Paratransit Service

Transit Usage

Disability/Health Condition Information

Application for SunDial Paratransit Service

Application for SunDial Paratransit Service

Transit Skills

Application for SunDial Paratransit Service

Application for SunDial Paratransit Service

Part B: Health Care Provider Certification

Part B: Health Care Provider Certification

Part B: Health Care Provider Certification

Part B: Health Care Provider Certification

Part B: Health Care Provider Certification