BICYCLE INTEREST FORM
Please answer the following questions to help us connect you with a bicycle.
First and Last Name
Best Way to Contact me:
I don't have access to email or phone
City of Residence:
MOST IMPORTANT reason for seeking a bicycle:
Primary mode of transportation
Exercise - Improve Health/Fitness
I will mostly ride on:
Paved Roads and Streets
Trails and unpaved surfaces
Mixture of on and off road
I would like my bike to have: (all that apply)
No Gears (Single Speed)
Multiple Gears / both Front and Rear
Coaster Brake (Pedal Backwards to Stop)
I'm not picky - anything is fine with me!
Rear Rack (extra cost)
I think my ideal bike is a:
Road Bike (Skinny Tires/ Aerodynamic Position)
Hybrid / Commuter
Never Ridden on 2 wheels
Beginner - Not confident yet / It's been a while
Intermediate - Fairly comfortable riding most places
Advanced - I am very comfortable on two wheels
I prefer to:
Earn A Bike (exchange volunteer service for a bicycle)
Purchase a bike
For Earn A Bike candidates, please indicate availability to volunteer.
Weekdays, during the day
Weekdays, later afternoon/early evening
Weekends, during the day
Weekends, later afternoon
I would rather not earn a bike.
I want to earn a bike, but not comfortable volunteering at the shop.
Some individuals may qualify for scholarship bikes, when both volunteer time and funds are limited due to circumstances. Please check any that apply to you. All answers are confidential.
I need a bike to get to my job or to school. (Currently employed/in school)
Receive government assistance (Food, Healthcare, Housing)
I am residing at Rowan Helping Ministries
Please add any comments that will help us match you with an appropriate bicycle.
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