2026 Rider Forms (Ride Voucher)

Ride Voucher (New Rider) Forms
Participant Registration Form

Required for grant funding
Name

First NameLast Name
Preferred Name
Gender
Date of Birth

MonthDayYear
Date
I declare that I am 60 years of age or older
Age Affidavit Signature
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Mailing Address (if different from home address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Ethnicity

Other
Race

Other
Do you understand English?
If the answer above was "No", which language do you speak?
Do you have a disability that limits activities such as mobility or selfcare?
Is your household income below poverty level?
Emergency Contact Name
Emergency Contact Relation
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you live alone?
Are you a veteran?
Income-Based Pricing
SRN's Ride Voucher program provides ride vouchers via Lyft Pass to make transportation more affordable for our Riders. The standard program provides passes valued at $12/pass. The income-based program provides passes valued at $16/pass. Riders in both programs will receive up to 8 one-way trips passes per month.

Our income-based program is available for those whose annual household income is at or below 200% of the Federal Poverty Level ($31,300 for an individual, $42,300 for two people, $53,300 for three) or who receive support of other income-based assistance programs (e.g. SNAP, TANF).
Do you qualify for income-based pricing? If yes, please see below for what is needed for income verification. We cannot process your passes until we receive that information.
If you answered the above question with "Yes" or "I am not sure", please send documentation showing ONE of the following. These can either be mailed to us at Senior Ride Nashville, 44 Vantage Way #450, Nashville, TN 37228, you can email them to us at info@SeniorRideNashville.org, OR you can submit it below.
- Proof that your annual household income is at or below $31,300 for an individual, $42,300 for two people, $53,300 for three. Acceptable documentation examples: bank statement, tax return, pay stubs, letter from employer, etc.
- Proof of enrollment in another income-based assistance program like SNAP, TANF, or similar. Acceptable documentation examples: acceptance/enrollment letter, copy of participant card, etc.
Upload your proof of income if you qualify for income-based pricing.

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Destination #1 - Please include Business Name (example: Kroger) and address
Destination #2 - Please include Business Name (example: Kroger) and address
Destination #3 - Please include Business Name (example: Kroger) and address
Destination #4 - Please include Business Name (example: Kroger) and address
Destination #5 - Please include Business Name (example: Kroger) and address
Please confirm that you have a Lyft account. Lyft Passes cannot be sent to you without a Lyft account.
Enter the mobile phone number that you use for your Lyft account.
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Ride Voucher (New Rider) Forms

Participant Registration Form

Income-Based Pricing