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Home My WebLink AboutRural_Program_Application Page 1 of 4 Application for the Rural Program (Over 60 & Under 60) The attached application must be completed to apply for the Under 60 and Over 60 rural transportation programs. See chart below for brief descriptions of each program. These programs are designed to provide transportation assistance to rural county residents that are elderly or disabled. *not available to the residents of Menasha, Neenah, and Oshkosh (where other comparable paratransit programs exist). GO Plus considers all information provided strictly confidential and will not share your answers with any other person or company unless authorized or legally required . If necessary, an appointment with Occupational Health may be scheduled by GO Plus to determine if your disability qualifies you for transportation assistance. Under 60 rural program applicants must re-apply each year. Over 60 applicants only need to apply once. Please return completed application to: Mail: GO Transit, 926 Dempsey Trail, Oshkosh, WI 54902; Fax: (920) 232-5343; or Email: transit@ci.oshkosh.wi.us Applicants need to complete all applicable parts of the form. Incomplete applications will not be processed and will be returned to the applicant. If you have any questions, please call GO Transit at (920) 232-5340. Successful applicants will be mailed a card with written instructions on how to use the program. For more information on paratransit programs provided by GO Plus, please call 232-5340. GO Plus is a service of GO Transit. Program (Card color) Eligible User Service Area Under 60 (Red)* Rural county resident that is disabled Winnebago County Over 60 (Blue)* Rural county resident over 60 years Winnebago County Page 2 of 4 Note: *If you are applying for the Over 60 rural program (applicant is 60 years of age or older), skip the questions in sections B & C and simply complete the last two lines of this application on the bottom of page 4 (signature, date, and daytime phone number). *Under 60 rural program applicants should complete all parts of this form. 1. Which of these mobility aids or equipment do you need to help you get to where you need to go? [Please check all that apply to you]  None  Manual wheelchair  Service dog  White Cane  Power wheelchair  Portable oxygen  Walker  Powered scooter/cart  Other __________________________ A. IDENTIFICATION INFORMATION B. MOBILITY INFORMATION PLEASE PRINT Name: ____________________________________________ Address: __________________________________________ City, State, Zip Code: ________________________________ New Address (if different): _________________________________ City, State, Zip Code: _____________________________________ Date of Birth (m/d/y): ________________________________ Home phone number: _____________________ Gender:  Male  Female Page 3 of 4 2. If you use a wheelchair or scooter while traveling, what are the specifications? Wheelchair/scooter Make Model How wide is it*? inches How long is it*? inches *measured 2 inches above the ground How heavy is it when occupied (total weight of chair and person)? pounds 1. Check any general medical conditions that you have:  None  Alzheimer’s Disease  Epilepsy  Multiple Sclerosis  Brain Injury  Guillian-Barre  Muscular Dystrophy  Cerebral Palsy  Hemiplegia  Paraplegia  Congestive Heart Failure  Huntington’s Chorea  Parkinson’s Disease  Cystic Fibrosis  Kidney Failure  Quadriplegia  Deaf-Blind  Legally Blind  Spina Bifida  Dementia  Lung Cancer  Stroke  Other _________________ 2. Is your health condition or disability temporary?    C. DISABILITY OR HEALTH CONDITION INFORMATION I don’t know  The ADA defines a “common wheelchair” as no more than 30 inches wide, 48 inches long, and 600 pounds when occupied. If your mobility device exceeds these dimensions, the ADA does not guarantee paratransit service. Page 4 of 4 3. Does your disability or health condition change from time to time in ways that affect your ability to travel?   No 4. In order for your request to be evaluated, it may be necessary to contact a physician or other professional to confirm the information that you have provided. Please complete the following information and authorization form. The following (check one) is familiar with my disability and is authorized to provide Occupational Health Systems with the information required to complete this certification.  Physician  Health care professional  Rehabilitation professional *Must be current physician or professional info. Professional’s name ___________________________________________ Address _____________________________________________________ City __________________________State ___________ Zip___________ Telephone number ____________________________________________ I solemnly affirm that the information I have provided on this application is complete and true to the best of my knowledge and belief and that intentional deception herein may be considered as significant cause for the disqualification from GO Plus Paratransit Programs. I will not loan my card to anyone. I also understand that my I.D. card may be confiscated by GO Plus if it is used improperly. I understand further that the GO Plus reserves the right to request additional information at its discretion. Signature of applicant or guardian (if appropriate): __________________________ Date: ___________ Daytime phone # (if proxy): ______________________