Online Application - Persons with Disabilities (PwD) Project : Eligibility and Registration - IndiGO

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Persons with Disabilities (PwD) Project Application

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If you would like to use this service, you may either download the .pdf version of the PwD application and send it along with a copy of one of the documents listed in Part 2 of the application to:

Indiana County Transit Authority
P.O. Box 869
Indiana, PA 15701
Fax: 724-465-1933

Or, you may complete this online application and separately send the required documentation as listed in Part 2 of the application to Indiana County Transit Authority. A .pdf copy of Supplement C "Certificate of Disability" will be included with your confirmation email for your convenience.

Once your application is received and reviewed you will be notified of your eligibility to participate.

If you have questions about this service, the application form or need the application form in an alternate format please call: 724-465-2140 or 1-800-442-6928. You may also email pwd@indigobus.com. Do not include any personal identifiable information in emails.

Note: The information provided in this application regarding your disability will be used to determine your eligibility for reduced fare transportation services under the PwD program. Other information within the form will be used for data collection purposes, to determine your eligibility for any additional transportation programs, and to provide you with the appropriate type of service. This information will be kept confidential and used only by professionals involved in evaluating your eligibility and in analyzing the program for future recommendations.

NOTE: You must have a valid email address to submit this form as a confirmation of your application will be emailed to you. If you do not have a valid email address, please download and complete the .pdf version of the application as per the instructions above. Thank you.

This application is processed on our secure server. If the web address of this page is not either
Secure | https://www.indigobus.com/PwD/pwd-application.asp -or-
Secure | https://www.indigobus.com/PwD/pwd_send.php,
or you do not see a padlock icon displayed on your browser, do not complete this form. If you have any doubts, Click to ensure that you are on Indiana County Transit Authority's secure server before proceeding.

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ALL FIELDS ARE REQUIRED UNLESS OTHERWISE INDICATED!

This application is:
A New PwD Application An Updated or Corrected PwD Applicaiton

PART 1: GENERAL INFORMATION

First Name:

Enter Your First Name

Last Name:

Enter Your Last Name

Middle Initial (optional):

Address (Street Number & Name):

Enter Your Address (Street Number & Name)

Address 2 (Apartment Number, etc) (optional):

Enter Your Address 2 (Apartment Number, etc)

City:

Enter Your City

State:

Enter Your State

Zip / Postal Code:

Enter Your Zip / Postal Code

Home Phone (###-###-#### format):

Work Phone:

Cell Phone:

You Must Enter A 10 Digit Phone Number in ###-###-#### Format

You Must Enter At Least One Contact Phone Number

Email Address:

Enter Your Email Address

A confirmation of this submission will be sent to this email address.

Country Of Residence:

Enter Your County of Residence

Birth Date (MM/DD/YYYY Format, e.g. 01/02/1955):

Enter Your Birth Date - mm/dd/yyyy format

Please indicate whether or not you have a disability according to Americans with Disabilities Act (ADA) definition below.

Do you have a disability according to the Americans with Disabilities Act (ADA) definition below? Yes No

If you do not have a qualifying disability as defined below, you are not eligible for the PwD Program.

Definition of Disability

Eligibility for this program is based on disability as defined by the Americans with Disability Act (ADA). According to the ADA, "Disability means, with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities of such individual; a record of such an impairment; or being regarded as having such an impairment". "...major life activities means functions such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and work."

PART 2: WRITTEN VERIFICATION THAT YOU ARE A PERSON WITH A DISABILITY

Written verification by a knowledgeable organization or qualified individual that you are a person with a disability is required to participate in the PwD project.

1. If you have written verification of a disability:

You may already have written verification that you are a person with a disability from a service organization by having an identification card, a written assessment of your disability, etc. If so, send a copy of this information to the transportation provider listed at the top of this form. If not, you will need to ask an organization or individual listed below to verify, in writing, that you are a person with a disability according to the ADA definition and then send it to the transportation provider listed at the top of this form.

Please check the organization or individual whose written verification you are submitting with your application form.

2. If you do not have written verification of a disability:

Please fill out a certification of disability form. It provides verification of a disability according to the definition in the Americans with Disabilities Act. This form can be used to acquire the necessary information for verifying a disability from a qualified health professional. Download Attachment C of the .pdf version of this application . After you complete the written certification, you may attach it to this application.

PART 3: INCOME AND HOUSEHOLD RELATED DATA

Passenger income related data is being collected for further decision-making regarding the project. THIS INFORMATION WILL NOT BE USED TO DETERMINE ELIGIBILITY FOR DISCOUNTED FARES UNDER THE PwD PROGRAM. Please check the appropriate space in each column:

Annual Income

Please Indicate Your Annual Income

Household Size

Please Indicate Household Size

PART 4: AVOIDING DUPLICATION OF TRANSPORTATION SERVICES

Transportation services provided under the PwD project are not to be provided in place of any current transportation services that you already receive.

Please select if you receive any transportation services or are any of your transportation costs paid for by another program or organization

1. Do you now receive any transportation services or are any of your transportation costs paid for by another program or organization?

No Yes

Make sure you complete all that apply from the following list.

Skip to Item 2.

If Yes, please complete all that apply from the following list.

Senior Citizens Shared-Ride Transportation Program

Area Agency on the Aging

Medical Assistance Transportation Program

Americans with Disabilities Act Complementary Paratransit

Mental Health/Mental Retardation (MH/MR)

Office of Vocational Rehabilitation (OVR)

The training program I am in at (location)

The employment program I am in at (location)

The group home where I live.

Other (please explain)

Please Indicate Any Transportation Services Your Currently Receive

2. If you are not registered for Medical Assistance (MA), you may qualify. If appropriate, you will be referred to the County Assistance Office (CAO) for a determination of eligibility for MA and other programs.

I have been informed of pending referral to the County Assistance Office (CAO)

- I was referred to the CAO for MA eligibility determination on (Referral Date): (01/02/1955 format)

Initials of staff person faxing the referral to the CAO

PART 5: INFORMATION SO WE MAY SERVE YOU BETTER

1. Is your disability permanent? Yes No
(A standard definition of a permanent disability is one that lasts for 12 months or longer.)

Please Indicate The Duration Of Your Disability

2. If not, how long is it expected to last?

3. What is the nature of your disability? Check those that apply.

Please Indicate The Type(s) of Disability

Mobility disability (please see question 4 below)

Vision disability

Hearing disability

Cognitive disability

Mental disability

Other - Please specify:

4. Please check all mobility aids that apply.

Please Indicate The Type Of Mobility Aid(s) Your Require

None

Manual Wheelchair

Power Wheelchair

Motorized Scooter

Crutches

Cane

Walker

5. Do you require the services of a personal care attendant or escort when you travel? (A personal care attendant or escort is a person that you need to assist you during the trip or at your origin or destination)

Yes No Sometimes

Please Indicate Whether You Need An Attendant or Escort Service

You will need to submit Supplement D - Application for Attendant with your PwD Application. A link is provided below. You may attach Supplement D to this application.

Please describe when you need assistance:

If you need a personal attended, you may complete Supplement D and attach it to this form. Supplement D - Application for Attendant

Please indicate when you need assistance.

6. Emergency Contact Optional

Emergency Contact Name:

Relationship:

Emergency Contact Home Phone (###-###-#### format):

Emergency Contact Work Phone:

Emergency Contact Cell Phone:

You Must Enter A 10 Digit Phone Number in ###-###-#### Format

7. Is there anything else you want us to know so we can serve you better?

Yes No

If "Yes," please describe:

IF APPLICABLE! Attach Scan or PDF of: Written Proof of Disability Certification Form; Supplement D - Application for Personal Attendant; or other applicable documents:
.pdf, .jpg, jpeg, .gif, .png only

PART 6: RELEASE OF INFORMATION and YOUR CERTIFICATION OF THE APPLICATION FORM

Release of Information

I give my permission to Indiana County Transit Authority to contact a health care or other professional that I designate for additional information to verify that I am a person with a disability.

Yes No

NOTE: While selecting "No" will not disqualify you from approval, it will delay your application as a Request To Release Medical Information will be mailed to you and your application will not be processed until it is signed and returned.

Name of the Person Who Completed This Form:

Check Here If Same As Applicant

First Name:

Enter Your First Name

Last Name:

Enter Your Last Name

Today's Date:

If the person who completed this form is not the applicant, you must provide the following information:

Relationship:

Please Enter Your Relationship To The Applicant And Your Phone Number

Phone Number:

You Must Enter A 10 Digit Phone Number in ###-###-#### Format

Before "signing" and submitting this form, please review the information as any errors or omissions will delay processing your application. Thank you.

I understand that the purpose of this application is to determine if I am eligible to participate in the PwD project. I certify that the information contained in this application is correct and truthful to the best of my knowledge.

ELECTRONIC SIGNATURE

Enter the birthday of the person who completed this form. (Format 01/02/1955):