Trishaw Pilot Application

Volunteer Pilot Application

We are pleased you are interested in volunteering as a pilot for the Sebastopol Area Senior Center's Trishaw Program. Please complete this application and we will get back to you as soon as possible.
Your contact Information
Name*

First NameLast Name
Sex
Date of Birth

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Your References

Please provide the name of 2 references
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Information
Name*

First NameLast Name
Relationship to you:*
Spouse, sibling, friend etc
Phone Number*
Please enter a valid phone number.
Program Information
Do you feel comfortable helping people in and out of the trishaw?
Do you have a cell phone to use in case of emergency?
Do you have any experience with bicycle maintenance?
Do you have any medical conditions that may affect your ability to participate in Cycling Without Age (heart conditions, vision difficulties, etc.)?
What is your experience with cycling?
Why do you want to become a Pilot for Cycling Without Age?
Should be Empty:

Your contact Information