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PARATRANSIT ELIGIBILITY APPLICATION
The Indianapolis Public Transportation Corporation (IndyGo) provides paratransit services in specially
equipped vans to persons who cannot utilize the regular bus system. To be eligible for this service,
individuals must have disabilities that prevent use of the regular fixed-route bus system. Eligible
individuals served do not have to reside in the area, but they must be traveling within the Open Door
service area. All applicants, whether new or applying for re-certification, must submit a new application
and professional verification form as well as complete an in-person assessment before your information
can be processed. The ADA certification process may include a functional assessment to determine if
and under what conditions you can use regular bus services. The assessment focuses on your abilities
and will be performed at no cost to you. After completing this application and the professional verification
form (completed by a physician or qualified certifying agent), please call 614-9260 to schedule your
functional assessment and bring your forms with you to the assessment.
If you have questions about the assessment process, please do not hesitate to call 614-9260 or email
assessments@indygo.net.
General Questions: (please print)
Check one:  New Application
 Renewal
Last Name: ________________________ First Name: _________________ ______ Middle Initial:
_____
Birth Date: _______ ____ Gender: Male ___ Female ___
Address: _______________________________________________________________ Apt.
__________
City: ____________________________________________________ State: ________ Zip:
__________
Phone Numbers: Home ____________________ Cell __________________
Work__________________
In case of emergency, contact:
Name: _________________________________ Relationship ____________________
Day Phone: ___________________________ Evening Phone: ____________________
Voluntary Questions: (This data is used for analysis only and will not impact eligibility for program
access.)
Ethnicity: __________ _____
Do you receive Medicaid? (Hoosier Healthwise) Yes___ No___
For Office Use Only.
1501Eligible?
W. Washington
Street  Indianapolis,
YES ____
No ____IN 46222  phone (317) 614-9260  fax (317) 614-9316
Application revised 6/2014 LSO
PCA? YES____ NO_____
ID #_____________
Date: ______
Approved/Declined by: ________________________________
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APPLICANT’S CERTIFICATION
Applicant’s Certification:
I understand that the purpose of this form is to determine if there are times that I cannot use regular city
bus services and therefore need the shared ride services of Open Door. I certify that the information
provided in this application is accurate and I understand that I must complete a functional assessment of
my abilities. My signature below also gives the Open Door Assessment Center permission to use data
gained from this assessment in research studies that will maintain my anonymity.
Signature: ____________________________________ Date: ________________
Person completing form for Applicant: ___________________________________
Relationship: __________________________________ Date: ________________
INFORMATION ABOUT YOUR CONDITION OR DISABILITY & MOBILITY AIDS
Which of the following mobility aids do you use? Please check all that apply.
_____Walking Cane
_____Manual wheelchair
_____White cane
_____Powered wheelchair
_____Walker
_____Prosthesis
_____None
_____Powered scooter/cart
_____Leg braces
_____Portable oxygen
_____Service animal
_____Crutches
_____Communication board
_____Other (please describe) ___________________________
How long have you used your current aids? __________________________________
If you use a wheelchair or scooter, is it:
30 Inches Wide or Less
Yes ____ No ____
48 Inches Long or Less
Yes ____ No ____
600 Pounds or Less when Occupied? Yes ____ No ____
Please describe your health condition/disability and how it prevents you from using the Fixed Route
buses:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________
1501 W. Washington Street  Indianapolis, IN 46222  phone (317) 614-9260  fax (317) 614-9316
Application revised 6/2014 LSO
3
Is this condition/disability temporary? Yes ____ No ____
If yes, what is the expected duration of this condition or disability? ______________
Does your condition/disability change from day-to-day in ways that affect your ability to use Fixed Route
service? Yes ____ No ____
(Please explain :)
___________________________________________________________________________________
___________________________________________________________________________________
__________________
Please read the following statements and check all of those that best describe what you believe are your
ability to use regular fixed route bus services by yourself.
_____ I use fixed route buses frequently.
_____ I can use the bus sometimes, in the right conditions
_____ I have difficulty understanding and remembering all of the things that I would have to do to use
Fixed
Route buses.
_____ I believe that I could learn to ride the bus, if someone taught me.
_____ I can get to and from the bus stop if the distance is not too great and the route is free of barriers.
_____
I can never use the bus by myself.
Do you need to travel with someone who assists you? Always ___ Sometimes ___ Never____
If you travel with someone who assists you, please describe how this person helps you:
___________________________________________________________________________________
___________________________________________________________________________________
__________________
YOUR FUNCTIONAL ABILITIES
Your answers to questions in this section will help us better understand your functional abilities in specific
areas. Your answers should be based on how you feel most of the time, under normal circumstances,
using your mobility aids, and whether you perform these activities independently or need assistance.
Please describe any problems you have getting to and from bus stops:
___________________________________________________________________________________
___________________________________________________________________________________
__________________
1501 W. Washington Street  Indianapolis, IN 46222  phone (317) 614-9260  fax (317) 614-9316
Application revised 6/2014 LSO
4
__________________________________________________________________________________
__________
Please describe any problems you have getting on, riding, and getting off the Fixed Route buses:
___________________________________________________________________________________
___________________________________________________________________________________
__________________
___________________________________________________________________________________
_________
Please describe any problems you have understanding and remembering how to use the Fixed Route
buses:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________
YOUR CURRENT TRAVEL
Please list your five most frequent destinations.
Place or Address
How do you get there now?
How often do you go there
in a month?
1.
2.
3.
4.
5.
Please use this space to tell us anything else you would like us to know about your travel challenges and
your ability to use Fixed Route buses or Open Door.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
____________________________________
1501 W. Washington Street  Indianapolis, IN 46222  phone (317) 614-9260  fax (317) 614-9316
Application revised 6/2014 LSO
5
Thank you for your time and input.
1501 W. Washington Street  Indianapolis, IN 46222  phone (317) 614-9260  fax (317) 614-9316
Application revised 6/2014 LSO