Senior Ride Program

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Are you stranded and need a ride? Check out our options below to see if you qualify.

We are a United Way Agency non-profit. The Senior Ride Program acknowledges that transportation plays a critical role in overall well-being, particularly in accessing healthcare services. A lack of reliable transportation can create significant barriers to medical care, leading to worsening health, social isolation, and a diminished quality of life.

This program provides free rides to non-emergency medical appointments for seniors and individuals with disabilities, offering door-to-door service to and from medical appointments.

Complete the application below to apply OR click here to download. If your application is approved, you will be certified to call and book.

For more information or to determine eligibility, please contact us at 205-322-5426.

First name

Last name

Address

State

City

Zip Code

Phone

ADDRESS DESCRIPTION:

Upload Photo ID

EMERGENCY CONTACT:

(name, relationship and daytime phone number)

REFERRAL SOURCE (Company, Name & Phone #):

PRIMARY DESTINATION: (Clinic Name)

Address

M.D.

Phone

PRIMARY HEALTH ISSUES:( Cancer, hypertension, diabetic, other)

SPECIAL ACCOMMODATIONS:

WC-Manual

WC-Electric

Lift

Other

IS THE PATIENT ABLE TO TRANSFER FROM WHEELCHAIR TO VEHICLE:

COMMENTS:

DOB:

Month

Day

Year

AGE:

GENDER

ETHNICITY

Household Members

HEALTH INSURANCE:

MONTHLY INCOME

SOC.SEC.(retirement):

SSD:

SSI:

TANF/CHILD SUPPORT:

PENSION:

NONE/OTHER:

VA:

TOTAL MONTHLY INCOME:

INCOME ADJUSTMENTS:

Rent/Mortgage:

Utilities

Medications:

Other:

ADJUSTED MONTHLY INCOME:

Upload Proof of Income

HOW WAS TRANSPORTATION PREVIOUSLY MANAGED?

DOES ANYONE IN THE HOUSEHOLD HAVE A CAR?

OTHER INFORMATION: