Seasonal Assistance

Bike Works Application

Bike Works Application

Please note that Bike Works cannot guarantee a bike to every applicant. In addition, bike colors and styles are not guaranteed.

First Name
Last Name
Country
Address Line 1
City
State
Postal Code
Phone
Alternate Phone
/
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Bike Requested For (Name)
If yourself, type "me"
Age
Weight (in pounds)
This information helps us determine the correct bike dimensions for the rider.
Height
Color of Bike
Please note that the color is not guaranteed.
Style of Bike
For example, "road bike" or "mountain bike." If unsure, type "unsure."
Phone
Alternate Phone
Do you need a helmet?
Do you need a helmet?
What is your intended use for a bicycle? (ex: riding to school, transportation to job, recreation, etc.)
Do you receive public assistance?
Do you receive public assistance?
Do you currently receive services from CAPTAIN CHS?
Do you currently receive services from CAPTAIN CHS?
If yes, what services?

By signing this form, you or the responsible parent/guardian for this child acknowledge CAPTAIN Community Human Services is not liable for any personal injury, loss of equipment, or damage to equipment sustained after leaving the premises.

Parent/Adult Signature (Typed)