Loan a Bike Request Form
Community Environment Alliance
First Name
Your answer
Last Name
Your answer
Address:
Your answer
City:
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Province:
Your answer
Postal code:
Your answer
Email:
Your answer
Phone number:
Your answer
Gender:
Age group:
Height (ft) (This information will be used to match a bicycle)
Your answer
Details
What would you use the bicycle for? Check all that apply.
Required
Tell us in what ways a bike will improve your quality of life:
Your answer
Loan a Bike Program Guidelines
Please read these terms and conditions carefully:

1. Loan a Bike program is based on an availability of bikes.

2. The bikes are loaned with a possibility of renewal based on availability.

3. It is the applicant's or parent/guardian's responsibility to ensure that the bike is in proper working order before using the bike; this includes brakes, steering, tires, and drive shaft including pedals.

7. You will be held financially liable for any repairs, loss or damage to the bike.

8. Report any loss of bicycle immediately to the police and CBC at 905-463-9941. Please provide a copy of the police report to CBC.

9. You shall not sell, charge assign, lease or otherwise dispose of the bike.

10. For your safety we strongly recommend you always wear a helmet while riding a bike.

11. You must use the bike in accordance with the Ontario's Highway Traffic Act (HTA) and all applicable laws and bylaws including use of proper reflectors and bicycle lights.

12. You must always lock the bike to a fixed object when unattended.

13. You must not ride the bike or allow it to be ridden if it is faulty or defective. If any problems are noticed then this should be reported to CBC at 905-463-9941 immediately.

14. By participating in the Loan a Bike program, the time spent biked during the loan duration will be contributed to the Bike4Health Campaign.

APPLICANT DECLARATION
To be signed by the applicant or authorized person upon submission of application. By submitting this application:
i) I am aware that the Community Bike Centre (CBC) is a project operated by the Community Environment Alliance (CEA) with an aim to connect people with bikes to better their lives. ii) I understand that CEA ultimately reserves the right to determine eligibility of recipients based on the applicant’s need and availability of bikes. iii) I certify all information I provide is true and accurate to the best of my knowledge at the time of this application.
I or parent/ guardian (if participant is a minor-under the age of 18) confirm to have read, understood and agree to the guidelines of borrowing a bike under the Community Bike Centre: Borrow-A-Bike program.
Required
I or parent/ guardian understand that borrowing a bike is based on availability of bikes.
Required
Disclaimer for Privacy
The information that you have provided is collected in accordance with Community Environment Alliance’s (CEA) Privacy
Policy, which has been created for compliance with Canada's Personal Information Protection and Electronic Documents
Act (PIPEDA) and Ontario's Personal Information Protection Act (PIPA). By providing your personal information on this
form, you are consenting to the collection of this information in order for CEA to better tailor client services. You may
request access to this stored information at any time, in accordance with CEA’s Privacy Policy. Please note that
Community Environment Alliance retains your consent until you withdraw it in writing.

CEA is committed to protecting personal information and does not sell trade or exchange personal information with third
parties.

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