GRANTED BIKE SURVEY
Please fill this out to the best of your ability. Please remember, only first names are needed, we keep any identifying information strictly confidential.
Sponsor Email (You)
*
example@example.com
Phone Number (SMS for pick up)
Please enter a valid phone number.
Requesting Organization
*
Name of granted bicycle recipient, minimum first name:
*
Name of person filling out this form:
*
Your relationship to the client:
*
Case manager
Pastor
Teacher
Physician
Employer
Coach
Other
How will the bicycle be used, check all that apply:
*
Going to school
Afterschool sports
Mental health enhancement or treatment
Physical health enhancement or treatment
Visiting friends/family
Tutoring/extended learning
Other
About the client, check all that apply:
*
Is a refugee
Is a foster child
Is a student (K-5th)
Is a student (5-8th)
Is a student (High School)
Other
Approx. height of child
On average, how miles does the child ride per week:
*
1-10 Miles per week
10-20 miles per week
20-30 miles per week
Over 30 miles per week
Today's Date
*
-
Month
-
Day
Year
Date
Voucher Pass Phrase
*
Submit
Should be Empty: