2019 Earn-A-Bike Application
Please fill out this form entirely. If a field does not apply, please write 'N/A'.
Do you currently own a bike? *
Please let us know why you need a bike from this program.
Your answer
First Name *
Your answer
Last Name *
Your answer
ZIP Code *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
How would you prefer us to contact you? *
Required
What is your current mode of transportation
Age *
Your answer
Height and Weight *
Your answer
What will the bike be used for?
Your answer
How often will you use the bike?
Specific Requests for the bike
Your answer
What days of the week are you available for community service?
Do you require any special work related accommodations?
Your answer
Are you interested in joining us on group rides?
How did you hear about WellBuilt Bikes?
Your answer
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