JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Bikes for All Client Request Form
This form is for folks who are eligible for the Bikes for All Program supported by the Steinman Foundation. Before proceeding please ensure the following:
You work with a partner agency that will be able to provide the contact information of a caseworker or program manager
You are an adult who is
not eligible
for our other programs
You were referred by a partner agency
You are seeking transportation for essential needs
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Client First Name
*
Your answer
Client
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Race
*
Black or African American
Hispanic or Latino
White
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other:
Preferred pronouns
*
they/them
she/her
he/him
Other:
Gender Identity
agender
androgyne
demigender
genderqueer or gender fluid
man
questioning or unsure
trans man
trans woman
woman
additional gender category/identity
prefer not to disclose
Other:
I identify as one of these marginalized groups:
*
Refugee or recently resettled person
Formerly incarcerated person
Person experiencing homelessness
Low-income individual seeking transportation
LGBTQIA+
Other:
Required
Client Current Address
Your answer
Client Email
*
Your answer
Client Phone Number
*
Your answer
Partner Agency
*
Church World Service
Tenfold
Gatehouse
Lancaster County Homelessness Coalition
ECHOS
CSG
LGH
Blueprints Recovery
Career Link
Other:
Which Common Wheel location would be for you to receive your bicycle and accessories?
324 N Queen Street, Lancaster PA 17603
137 Locust Street, Columbia PA 17512
Clear selection
Name of Social Worker or Program Manager
*
Your answer
Social Worker or Program Manager's email address
*
Your answer
Social Worker or Program Manager's phone number
*
Your answer
Your height
Your answer
Your weight
Your answer
What accessories do you need for your bicycle? Please note: we provide a helmet, a u-lock, and a light set. We encourage you to think about what you might need to get to work or to make your commute easier via bicycle
Your answer
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Common Wheel.
Does this form look suspicious?
Report
Forms
