Amazing Gracie's Great Bike Giveaway Entry Form
Amazing Gracie's Great Bike Giveaway was created to celebrate the siblings of special needs children and their families by throwing a party in their honor, recognizing them and giving them a bike. If you are a special needs family and bikes would be helpful to the siblings of your special needs child, please apply here. DEADLINE: May 1, 2018
Email address *
Parent/Guardian Name *
Your answer
Name of your child with special needs and diagnosis/medical conditions:
Your answer
Phone Number (Mobile) *
Your answer
Mailing Address (entire address) *
Your answer
Please list the siblings in your family in need of a bike. Please utilize the chart below to determine what size bike you need for your child. All four components must be listed about each child: Name/Gender/Age/Bike Size. All information must be provide on this form to be considered for a bike. Children not listed on this form will not receive a bike.
Sibling #1: Name/Gender/Age/Bike Size *
Your answer
Sibling #2: Name/Gender/Age/Bike Size
Your answer
Sibling #3: Name/Gender/Age/Bike Size
Your answer
Sibling #4: Name/Gender/Age/Bike Size
Your answer
Sibling #5: Name/Gender/Age/Bike Size
Your answer
Tell us your story and let us know why you would like to see the siblings in your family to honored: *
Your answer
Please list all social media we can follow to learn about your journey: *
Your answer
How did you find out about Amazing Gracie's Great Bike Giveaway *
By selecting this box, you agree that if selected, photos of your family and the likeness, thereof, can be used for promotion of Amazing Gracie's Legacy and the events that we sponsor. *
Required
By selecting this box, you agree that Amazing Gracie's Legacy and all parties associated with this non-profit hold no liability associated with any and all bike(s) and equipment that you and your family receive. *
Required
Amazing Gracie's Legacy reserves the right to determine the families selected, based on reviewing the information provided on this form. Only applications submitted through this online form will be considered. *
Required
I agree that all information submitted is truthful and accurate. By typing your name below, it acts as your signature. *
Your answer
A copy of your responses will be emailed to the address you provided.
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