Custom Rifton Bike Nomination
Please note: Submitting a nomination does not guarantee selection. All nominations will be carefully reviewed, and every nominee will receive an email regarding the final decision.
Before you begin
Thank you for your interest in our Custom Rifton Adaptive Bike donation. This bike is being provided by Rifton through From We Can’t to We Can to help a child or an adult gain greater independence, inclusion, and opportunities for recreation.
If you forgot your member ID or if you’re unsure if you have one, do no fill out a member form. Email pferrari@wecant2wecan.org
Member ID (You MUST have this to continue)
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Visit wecant2wecan.org/joinus to receive a memberID
Completing this application does not guarantee selection. 1. One applicant will be selected to receive a custom Rifton adaptive bike. 2. All nominations will be reviewed by our team. 3. Every applicant will receive an email with the final decision. 4. The selected family must be willing to work with our team to complete the rifton bike process. 5. Only ONE application per nominee. Do not submit more than one application per nominee
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I have read and understand the above.
If the nominee is selected, I understand that the custom Rifton adaptive bike will be presented during From We Can't to We Can's 8th Anniversary fundraiser, Roar For A Reason, on September 12th, 2026 at the Edelman Fossil Park in Mantua, New Jersey. I understand that the nominee's parent or legal guardian is responsible for attending the event, arranging transportation, and picking up the bike unless otherwise approved by the organization.
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I understand and agree.
Your Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Relationship to the nominee
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Parent
Sibling
Teacher
Family Member
Therapist
Physician
Other
Please select the state where the nominee resides.
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New Jersey
Pennsylvania
Delaware
New York
Other (Not eligible)
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Disability Information
Does the nominee currently receive Physical Therapy?
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Yes
No
If yes, please list therapy facility.
Has the nominee’s physical therapist recommended an adaptive trike?
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Yes
No
Unsure
Does the nominee currently use any mobility equipment?
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Manual Wheelchair
Power Wheelchair
Walker
Gait Trainer
Stander
Other
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Adaptive Bike Information
Has the nominee ever had an adaptive bike?
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Yes
No
If yes, please tell us about it.
Has insurance ever denied coverage for an adaptive bike?
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Yes
No
Never applied
Why is an adaptive bike needed? Please explain how receiving a custom Rifton adaptive bike would impact the nominee’s daily life, independence, recreation, or overall quality of life.
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Tell Us About the Nominee
Share their personality, interests, hobbies, favorite activities, accomplishments, and what makes them special.
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What would receiving this adaptive bike mean for the nominee and their family.
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Why are you nominating this nominee?
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AGREEMENTS & ACKNOWLEDGMENTS
If the nominee is selected as a finalist, From We Can't to We Can may request additional documentation, such as a recommendation from the nominee's physical therapist or physician, to assist with the custom fitting process.
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I understand and agree.
If the nominee is selected as a finalist, I understand that the nominee's parent or legal guardian will be required to participate in a brief Zoom interview with From We Can't to We Can. This interview helps our team verify the information provided in this nomination, learn more about the nominee's needs, and ensure the adaptive bike is awarded to the family that best fits the purpose of this program.
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I understand and agree.
If selected, I grant From We Can't to We Can permission to photograph, film, and share the nominee's story to recognize our donors, promote the nonprofit's mission, and inspire future support.
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Yes, I grant photo/video permission
I certify that the information provided in this nomination is true and accurate to the best of my knowledge.
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I understand and agree.
I understand that submitting this nomination does not guarantee that the nominee will be selected to receive the adaptive bike. All nominations will be carefully reviewed, and the nominee's family will be notified of the final decision by email.
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I understand.
Today's Date
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Month
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Day
Year
Date
By typing my name below, I confirm that I have read, understood, and agreed to all terms above. I acknowledge that this electronic signature is legally binding. Parent/Guardian Full Legal Name:
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Submit
Should be Empty: