Lighthouse Community Center
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Proof of ID
Do you have a bike lock?
Approximate Height (Feet, Inches)
Are you receiving any sort of income?
If Yes, please explain.
How will having a bike benefit you?
By signing this application, you (the applicant) verify that all information is accurate and correct. The applicant agrees that they will provide their own means of securing the bicycle. Additional proof of a bicycle lock may be requested upon the discretion of the service provider by the applicant presenting the lock at the time of receiving the bicycle. Any maintenance by the service provider will be for a fee of an amount at the discretion of the service provider. Failure to receive the applicant’s bicycle at the pick-up date may result in the forfeiture of services and/or require a new application.
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