NSH Outreach Transportation Form
The transportation give-a-way is designed to help the residents of Jefferson County. Please complete the form or share this information with someone that can benefit from either of these services. We have limited bikes, we will contact you if you have been selected.
Date of Submission
Name (First and Last Name)
What is your billing address (Street, City, State and Zip)
What is your contact number
What is your email address
What size bike are you requesting? (One request per person)
20 Inch (3'2"' - 4'4")
24 Inch (4' - 5'4")
26 Inch (5'2" - 6'4")
27 Inch (6' - and above)
During the pandemic, we know that some of been impacted more than others in our community. Please state how you can benefit from a bike. You will be contacted if you are selected. Thank You.
Send me a copy of my responses.
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