GRANTED BIKE SURVEY
Please fill this out this form for your client. Incorrect/incomplete forms will not be processed. Please remember, only first names are needed, we keep any identifying information strictly confidential. Bike MUST be picked up within 7 days or will be surrendered to the next client.
Sponsor Email (You)
*
example@example.com
SMS for pickup notification (Phone Number)
*
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
Social Worker
Physician
Parole Officer
Doctor
Pastor
Teacher
Other
How will the bicycle be used, check all that apply:
*
Looking for employment
Maintaining employment (already have a job)
Mental health enhancement or treatment
Physical health enhancement or treatment
Going to doctor's appointments
Going to school
Other
About the client, check all that apply:
*
Is a veteran
Is currently unhoused
Is a refugee
Is replacing a stolen bike
Is a student
Is a teacher
Is a homeless advocate
Other
Approx. height of client
*
Will this bicycle be used in making money, check all that apply:
*
Collection of recyclables
Window washing
Car detailing
Curb painting
Bike courier/shopping
Other
On average, how miles does the client ride per week:
*
1-10 Miles per week
10-20 miles per week
20-30 miles per week
Over 30 miles per week
Does the client use public transportation, check all that apply:
*
VTA bus
VTA light rail
Caltrain
Today's Date
*
-
Month
-
Day
Year
Date
Does the client need a Caltrain Go Pass?
*
Yes
No
Does the client own a car?
*
Yes
No
Submit
Should be Empty: