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Step 3

Apply for Service

Thanks for taking the time to verify your eligibility for Easy Does It Emergency Services. We've reviewed your information and confirmed you're eligible to continue. Please fill out all the required fields to complete your application for service. Upon completion of this form, you'll have access to Wheelchair Repair and Attendant Care. But will need to apply for ride vouchers through The City of Berkeley to use our Transportation Program.

Contact Details

First Name

Last Name

Contact Type

Referral

Disability Information

Primary Disability

Speech Disability

Other Disabilities

Select all that apply

Measure E Qualifications

Do you live or work in Berkeley?

Are you visiting Berkeley?

Do you need personal assistance with least one activity of daily living due to substantial disability-related limitations?

Examples: dressing, meal preparation, transferring, toileting, housekeeping, taking medication, mobility

Qualifies for Measure E

UCB Affiliation

Affiliation

Address Information

Primary Mailing Address Type

Mailing Street

Mailing City

Mailing State

Mailing Zip/Postal Code

Page 2

Phone Contact Information

Preferred Phone Type

Home Phone

Work Phone

Email Contact Information

Personal Email

Would you like to be added to our email list?

Would you like to receive your invoice electronically?

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Age Information

Birthdate

Age Range

Demographic Information

Gender

Race

Hispanic or Latino?

Veteran Status

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Income Information

Yearly Income

Source of Household Income

Non-Cash Benefits

Other Income Source

Level of Household Income

Please refer to table below for guidelines

Household Information

Housing Type

Household Type

Number of Persons in Household

Single Female Head of Household?

Number of Minors in Household

Work Status (18+)

Are you between the ages of 14-24 and do not work or go to school?

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Health Insurance & Education

Health Insurance Source

Education Level

East Bay Paratransit & BRSD

Do you use East Bay Paratransit?

Do you know about the Berkeley Rides for Senior and Disabled Voucher Program?

Are you signed up for Berkeley Rides for Senior and Disabled Voucher Program?

Preferences

Do you have a gender preference for an attendant/caregiver?

If the caregiver of your preferred gender was not available would you use EDI's services?

You answered No or Maybe to the previous question, please explain how you would get your needs met?

In Home Support Services Information

Do you receive In Home Supportive Services (IHSS)?

Are you a Regional Center Client?

Registration Date

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