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Seasonal Assistance

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/Province *
Postal Code *
Month
/
Day
/
Year
If yourself, type "me"
This information helps us determine the correct bike dimensions for the rider.
Please note that the color is not guaranteed.
For example, "road bike" or "mountain bike." If unsure, type "unsure."
Do you need a helmet?
(ex: riding to school, transportation to job, recreation, etc.)
Do you receive public assistance?
Do you currently receive services from CAPTAIN CHS?

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.

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