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2. 
   Jitney Senior Transportation Program
   
   Please use the interactive online form below to apply for the Jitney Senior Citizen Transportation Program (seniors over 60).
4. 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.
6. Client Information
8. Name*
9. Date of Birth*
   Date of Birth
11. Address*
13. Town*
14. State*
15. Zip*
17. Home Phone
18. Cell Phone
20. Emergency Contact Name / Relationship*
21. Emergency Contact Number*
23. Transportation Service Required*

    1. Food Shopping

    1. Medical
24. Does anyone in your household operate a vehicle?
    -- Select One --YesNo
28. Primary Care Physician Information
30. Name*
32. Address*
34. Town*
35. State*
36. Zip*
38. Phone
39. Fax
43. Do you receive any of the following?*

    1. Medicaid

    1. Workman's Compensation

    1. Other
45. Are you a Town of Brookhaven Resident?*

    1. Yes
    2. No
47. If applying for temporary transportation, specify start / end date:
    If applying for temporary transportation, specify start / end date: Start Date

    —

    If applying for temporary transportation, specify start / end date: End Date
49. If you live in a complex, what is the name?
51. What is your nearest cross street?
53. Is your address visible on your residence?*

    1. Yes
    2. No
55. Are you able to see the bus when it arrives to pick you up?*

    1. Yes
    2. No
57. Are you under the age of 60 and classified as disabled?*

    1. Yes
    2. No

    If yes, medical documentation must be obtained.
59. Would you be required to be transported in your own wheelchair or scooter?*

    1. Yes
    2. No

    If using a scooter you must transfer into a regular seat.
61. Would you need to be boarded onto the vehicle in our wheelchair?*

    1. Yes
    2. No

    If yes, once boarded, you will be required to transfer to a regular seat.
63. Do you require portable oxygen?*

    1. Yes
    2. No
65. Do you suffer from seizures?*

    1. Yes
    2. No
66. If yes, when was your last seizure?
    If yes, when was your last seizure?
68. Do you or anyone in your household operate a motor vehicle?*

    1. Yes
    2. No
69. Do you reside with family members?*

    1. Yes
    2. No
71. Additional Information
73. 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.
75. 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.
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80. 1. Receive an email copy of this form.
81. Email address

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82. Submit

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