download the form
Optional: To download the application, fill it out and send it in, please click here to download.
Please fill out this form completely. Uncompleted forms will be discarded.
Fields marked with * are required.
If you have mobility difficulties that limit you from using the fixed route accessible buses, you may be eligible to participate in Coast RTA’s Paratransit Program. Please complete all the information below so that the Coast may assist you with your transportation needs.
I agree that I will pay the exact fare, if required, for each trip. I agree to notify Coast’s Paratransit office of any changes in my staus which may affect my eligibility to use the service. I also understand that failure to adhere to the policies and procedures will be grounds for revoking my application and the right to participate in the program. I understand and agree to hold Coast RTA Waccamaw Regional Transportation Authority harmless against all claims or liability for damages to any person, property, or personal injury occuring as a result of my failure to equip or maintain the safety measures of the adaptive equipment or certified guide/service animal that I require for mobility. I have read and fully understand the conditions for service outlined above and agree to abide by them.
Certification of Eligibility Release
I hereby authorize the release of the certification information and any additional information to Coast RTA Waccamaw Regional Transportation Authority for the purposes of evaluating my eligibility to participate in Coast RTA’s Paratransit Program. I further understand that any such information will be kept confidential.
This certified that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
If you click submit, you are giving Coast RTA your electronic signature, which is binding in a court of law.