Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Jitney Transportation Program Application (seniors over 60)

  1. Town Seal
    Jitney Senior Transportation Program
    Please use the interactive online form below to apply for the Jitney Senior Citizen Transportation Program (seniors over 60).
  2. The Jitney Transportation Program is a shared ride, curb to curb service provided within the Town of Brookhaven to our Senior Citizens (over 60) and Disabled residents who have no other means of transportation. Transportation is provided to doctors and shopping. The fare is $3 round trip. Transportation hours are Monday through Friday from 8 a.m. to 2:30 p.m. Call 631-451-9081 for more information. Please use the online application to request services from our Jitney Transportation Program.
  3. Client Information
  4. Transportation Service Required*
    1. Primary Care Physician Information
    2. Do you receive any of the following?*
    3. Are you a Town of Brookhaven Resident?*
    4. Is your address visible on your residence?*
    5. Are you able to see the bus when it arrives to pick you up?*
    6. Are you under the age of 60 and classified as disabled?*
      If yes, medical documentation must be obtained.
    7. Would you be required to be transported in your own wheelchair or scooter?*
      If using a scooter you must transfer into a regular seat.
    8. Would you need to be boarded onto the vehicle in our wheelchair?*
      If yes, once boarded, you will be required to transfer to a regular seat.
    9. Do you require portable oxygen?*
    10. Do you suffer from seizures?*
    11. Do you or anyone in your household operate a motor vehicle?*
    12. Do you reside with family members?*
    13. I am aware that the Town of Brookhaven’s Jitney Transportation Program provides only minimal ambulatory assistance. In the event medical documentation is needed to process this application, I hereby give my permission for the stated program to secure medical information from my physician regarding my medical diagnosis and/or treatments as well as any disability restrictions. All such information is to be held in strict confidence and used solely to enable the Jitney Transportation Program to provide safe and appropriate transportation.
    14. Please allow 7 to 10 business days for processing and determination. If you wish to contact the Jitney Office directly, please call during regular business hours 7 a.m. to 3:30 p.m. (EST) at 631-451-9081.
    15. Leave This Blank:

    16. This field is not part of the form submission.