Village Wrench Earn-a-Bike Form
Use this form to document your Organization Referral OR your contact information and community service hours. The Village Wrench staff will use it to set you up with the best bicycle for you!

Earn-a-Bike Details:
5th Grade and Under: 5 hours (Hours can be completed in the form of organic service such as helping others in the community, i.e. yard work for a neighbor, picking up trash with a group etc)
10 Hours = $100 Bike
20 Hours - $200 Bike
You can combine service and payment (EX: 10 hours + $50 = $150 bike, 20 hours + $100 = $300 bike)

Earned bicycles include a helmet. You may purchase a lock and light package for $10. ONCE COMPLETED, call the Village Wrench shop during our hours to inquire about bike sizes and availability. We cannot guarantee that we will have the right bike for you right away, as our selection is based on refurbished donations. When we approve, take this form to Village Wrench during shop hours. 

1186 Pendleton St Greenville, SC 29611
Tuesday - Friday 10a-6pm/ Saturday 10a-2pm
864-248-6243          vw@millcommunity.org  www.villagewrench.org/earn-a-bike

Community Service Opportunities & Ideas: See the website for a list of partner organizations who have agreed to let you serve; kids qualify to do organic service that helps others in your community, like yard work for a neighbor or picking up trash with a group who can confirm your service.
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Email *
Today's Date *
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Earner Name *
Height *
Type of Bike preferred *
Required
Gender *
Referral Programs: If you are completing Earn-a-Bike in partnership with another human services, youth program, or school in Greenville, please list it
Referral Reference Point of Contact Name
If you are currently houseless, please list the program or homeless shelter you are residing in. If other, explain.
Email Address *
Telephone # *
Date of Birth *
MM
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DD
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Age *
For Adult Earners: Employed?
Clear selection
For Adult Earners: Income Range
Clear selection
For Adult Earners: Do you receive supplemental income (disability/SSDI, SSI, or other subsidy)?
Clear selection
Highest Level of Education
Household Size (# of people living in house)
Liability + Photo & Media Release
I have completed the below stated work in order to earn a bicycle through Village Wrench. I affirm that the information provided is true to the best of my knowledge. I have read the rules on the earn-a-bike website page and also understand that earning a bicycle is a privilege that can be revoked by Village Wrench if policies are broken.
If <18, parent/guardian acknowledgement and agreement on behalf of your child.

I understand that photos and videos may be taken during Village Wrench activities, and I authorize Village Wrench to use such media on or in its website, in newsletters, social media, or other forms.

Type your name as an electronic signature agreeing to this statement: I have read the Liability release form and have full understanding of the consequences for not following the rules. I understand that participating in Earn-a-Bike, 6-Cycle, or any other Village Wrench programs is a privilege that can be revoked at any time and that the rules and regulations may be changed at the discretion of Village Wrench’s leadership team. *
Service Activities Tracking Sheet
Kids in 5th grade or below only need to complete 5 hours to earn their bicycle! You may complete 10 hours of service for a bike that costs $100 or less. You may complete 20 hours of service for bicycles up $101-$200. All service must be verified by a supervisor OR a verification letter should be emailed to vw@millcommunity.org or brought to the shop.
Total Number of Community Service Hours Completed
Clear selection
Specific Total Number of Hours *
Service Activity 1: List date, service activity, number of hours, and the organization *
Supervisor Name *
Supervisor Phone Number *
Service Activity 2: List date, service activity, number of hours, and the organization *
Supervisor Name *
Supervisor Phone Number *
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