Partner Agency Ride Voucher Form
Participant Registration Form
Required for grant funding
Name
*
First Name
Last Name
Preferred Name
*
Senior Residence Name
*
Gender
Female
Male
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I declare that I am 60 years of age or older
*
Yes
No
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
City
State / Province
Postal / Zip Code
County
*
Mailing Address (if different from home address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Other
Race
*
American Indian/Alaskan Native
Black/African American
Non-Minority (White, Non-Hispanic)
White, Hispanic
Asian
Native Hawaiian/Other Pacific Islander
Other
Do you understand English?
*
Yes
No
If the answer above was "No", which language do you speak?
Do you have a disability that limits activities such as mobility or selfcare?
*
Yes
No
Is your household income below poverty level?
*
Yes
No
Emergency Contact Name
*
Emergency Contact Relation
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you live alone?
*
Yes
No
Are you a veteran?
*
Yes
No
Please confirm that you have a Lyft account. Lyft Passes cannot be sent to you without a Lyft account.
*
Yes, I have a Lyft account.
Enter the mobile phone number that you use for your Lyft account.
*
Submit
Should be Empty: