2026 Rider Forms (Ride Voucher)

Ride Voucher (New Rider) Forms
Participant Registration Form

Required for grant funding
Name*

First NameLast Name
Preferred Name*
Gender

FemaleMale
Date of Birth*

MonthDayYear
Date
I declare that I am 60 years of age or older*

YesNo
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*

Hispanic or LatinoNot Hispanic or LatinoOther
Race*

American Indian/Alaskan NativeBlack/African AmericanNon-Minority (White, Non-Hispanic)White, HispanicAsianNative Hawaiian/Other Pacific IslanderOther
Do you understand English?*

YesNo
If the answer above was "No", which language do you speak?
Do you have a disability that limits activities such as mobility or selfcare?*

YesNo
Is your household income below poverty level?*

YesNo
Emergency Contact Name*
Emergency Contact Relation*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Do you live alone?*

YesNo
Are you a veteran?*

YesNo
Income-Based Pricing
SRN's Curb-to-Curb program provides ride vouchers via Lyft Pass to make transportation more affordable.

The standard pricing for this program is $8 per one-way trip. SRN covers the cost directly to Lyft and the following month SRN bills the rider $8 per completed trip.

Income-based pricing 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. *

NoYesI am not sure
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.

Cancelof
Curb-to-Curb Sign Up Details
SRN's Curb-to-Curb program is for trips to/from health and wellness visits. Riders receive vouchers for 4 one-way trips per month. Riders must provide SRN with a list of (up to 5) addresses to health and wellness destination they will use (this is a grant requirement - grant funding makes this program possible). Destinations allowable as health and wellness addresses include: doctor's offices, dentists, therapy, pharmacies, grocery stores, fitness centers, and places of worship.

If you do not provide these addresses, we cannot create your Lyft Pass. A minimum of 1 address is required.
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
Should be Empty:

Ride Voucher (New Rider) Forms

Participant Registration Form

Income-Based Pricing

Curb-to-Curb Sign Up Details