Uber Voucher Request Form Driving Hope: Uber & SBTF Remove Transport Barriers for Brain Tumor Patients Please enter the information below to request an Uber/Uber Eats (ride or mobile meal delivery) voucher for a single patient. If you need a voucher for more than one individual, you will need to submit a separate request for each. While the voucher is intended to support the patient, we understand it may be sent to or redeemed through a caregiver’s Uber account if needed. Please allow up to 48 business hours for the voucher to be received, though many are sent sooner. All vouchers expire 15 days after issuance. Accurate contact information is required to successfully receive the voucher. Date of Request (month, day, year)(Required) MM slash DD slash YYYY Example: January 7, 2025, 01.07.25, Jan. 7, 2025 Name of Person Entering Request (enter first and last name)(Required)Email of Person Entering Request (not email of patient)(Required) Patient Information Please provide the patient’s name, medical department, and treatment center or hospital affiliation. Include a brief description of why assistance is being requested for the patient. This information helps us better understand the patient’s needs and personal information will be kept confidential. Patient's First and Last Name (person receiving voucher)(Required)Patient's Medical Department (Example: neurosurgery, neuro-oncology, PT/OT, oncology, infusion, etc)(Required)Name of Patient's Treatment Center/Medical Facility/Hospital Affiliation(Required)Short description of why requesting assistance for patient(Required)Uber Account Holder Information Please enter the name, phone number, and email address of the Uber account holder who will receive the voucher (this may be the patient or a caregiver). Please ensure the Uber account receiving the voucher has download the Uber app on their phone, the account is active and has a personal credit or debit card attached to cover any charges exceeding the voucher amount. The information must match the Uber account exactly to ensure successful voucher delivery and cannot be edited after submission. All details are kept confidential and will not be shared or used for solicitation purposes.Uber Account Holder's Name (this may be the patient's or caregiver's Uber account)(Required)Uber Account Holder's Phone Number (phone number listed on the Uber account)(Required)Uber Account Holder's Email (email address listed on the Uber account)(Required) Enter Email Confirm Email Amount requested(Required) $50 $100 Other (any amount over $100, at your discretion) Mark only one circle Other (any amount over $100, at your discretion)
