2026 Single Mom Saturday - Appointment Form

SINGLE MOM SATURDAY

Complete the form for a FREE Oil Change from generous vendors, Delaware Electric Coop, and The Bridge!

What is your name?*

First NameLast Name

What is your e-mail address?*
example@example.com

Cell Phone Number*
Please enter a valid cell / mobile phone number.Format: (000) 000-0000.
I agree to receive messages sent via an automated texting platform from The Bridge, and this agreement isn’t a condition of any purchase. I also agree to the Privacy Policy on our website. Message frequency may vary. Message and Data rates may apply. Text STOP to opt out anytime, and text HELP for more information.
Read The Bridge Privacy Policy on our website.

What is your address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How many children do you have?*
Child 1 Age
Child 2 Age
Child 3 Age
Child 4 Age
Child 5 Age
Child 6 Age
Child 7 Age
Child 8 Age
Child 9 Age
Child 10 Age

Gibbons Auto Parts and Repairs - Pocomoke, MDWhalen's Auto Repair and Tires - Cape May Courthouse, NJPrice Honda - Camden, DEPrice Premier - Rehoboth Beach, DEPrice Toyota - New Castle, DEFrederick Ford - Seaford, DEMeineke – Milford, DEOne Stop - Milford, DETJ's Beach Bays - Lewes, DE

Gibbons Auto Parts and Repairs - Appointment Times*
Whalen's Auto Repair and Tires - Appointment Times*
Price Honda - Appointment Times*
Price Premier - Appointment Times*
Price Toyota - Appointment Times*
Frederick Ford - Appointment Times*
Meineke Car Care - Appointment Times*
One Stop Auto - Appointment Times*
TJ's Beach Bays - Appointment Times*

What year is your vehicle?*
What is your vehicle make?*
What is your vehicle model?*

What is your Vehicle Identification Number (VIN)*

Please Read the Single Mom Saturday Waiver and Release:
I attest that I am the individual identified in this application.
I certify that: (a) I am not an employee, officer, director, or agent of Sponsor, nor am I an immediate family member or member of the household of any such individual; (b) I am an unmarried mother; (c) I am 18 years of age or older; and (d) I have read and understand this Liability Release Form.
I understand that this donation is sponsored by The Bridge of Hope Inc. (“Sponsor”). I understand that I am solely responsible for any and all costs, fees, taxes and expenses associated with the donation, receipt, possession, and use, and all applicable federal, state, and local taxes and any other expenses and costs not expressly listed above.
I, to the fullest extent permitted by law, release Sponsor, its subsidiaries, affiliates, distributors and related companies and each of their respective officers, directors, employees and agents from any and all liability, claim, injury, loss, cost, expense (including reasonable attorneys’ fees), or damage of any kind, directly or indirectly, in whole or in part, including without limitation, economic damage, property damage, personal injury, disability or death, arising out of or in connection with the donation or from the receipt, possession, use or misuse of the donation. Once I receive the donation, I understand that there can be no claims for liability made against the above-named sponsors or parties.
YES - I agree to grant The Bridge, The Bridge of Hope, and its authorized representatives permission to use recorded video and/or captured photographs of my participation in their event(s). I further agree that any or all of the material photographed or videoed may be used, in any form, as part of any future social media/website posts, publications, brochures, or other printed materials used to promote The Bridge, The Bridge of Hope; or sponsoring organization, and further that such use shall be without payment of fees, royalties, special credit or other compensation.NO - I do not grant my permission.

Do you have any special requirements or requests?
Should be Empty:

SINGLE MOM SATURDAY