Expression of Interest

Expression of Interest

This form to be used to inquire into the Cycling WIthout Age - Mississauga program
Your Name*

First NameLast Name
Your preferred Email address*
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main (Cell) Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Do you have WhatsApp on this number?*

YesNo
Secondary (Home) Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Let us know what is the best time to call if preferred: Daytime AM.
Alternate time if possible: EveningPM.
For those wanting to be involved in the program, please indicate your intention below (check all that apply):

Being a pilot; (training, vaccine and documentation* required) for a few hours a monthBeing a 'Bike Buddy'; volunteer a few hours a month with your own bicycleRetirement home Co-ordinator; (for Residence staff) to enroll passengersCaptain; to approve and assign PilotsCWAM Ambassador; to promote the Cycling Without Age program in MississaugaCWAM Advisor; should be familar with local cycling infrastructure & community and/or aging and disabled communities in MississaugaCWAM Support, IT, Social Media, Website, Grant writing, Pilot training, Accounting & book-keeping
* For a Level 3 Vulnerable Sector Police clearance check you may need a letter of request from us to avoid paying for it. Please indicate below if you need one emailed to you.

Yes, Please email me a Police Check request letter. It may take a few days to provide one.
* I understand that some retirement residences may require a negative TB test to volunteer with their residents. It may not be covered by OHIP if not medically indicated

If assigned to one of these rides I will provide documentationI prefer not to be assigned to rides requiring this documentation
* Pilots are required to know and understand the traffic rules in the event that the trishaw needs to be ridden on the public roadways. You may have to provide a driver's licence for insurance purposes.

I understand and agree to provide documentation prior to riding with passengers
Should be Empty: