Earn-a-Bike 2019 Registration Form
Please complete this form to register a student for a 2019 Earn-a-Bike program. Once you complete this form and click "submit" we will be in touch to confirm your student's spot in line for a program session. Call with any questions: 269-365-9142!

The Winter Earn-a-Bike program will take place on Tuesday nights from 5:30-7:30pm starting January 23 and running weekly until February 27 for a total of six sessions.

*Note: Earn-a-Bike programs are open to all students 10-15 years of age. Earning a bicycle at Open Roads is about gaining independence and self-sufficiency, learning how to be active and healthy, having a community to learn and grow with, and feeling safe and supported! ***Students ages 15-18 in immediate need of a bicycle for transportation purposes should contact our office at 269-365-9142.​

*Full scholarships are available for students who need one. Payment is NEVER a barrier for students who want to participate. Please learn more about this in our "Need" section at the end of this form.

The Basics
Adult Contact Name (first and last) *
Your answer
Adult Contact PHONE NUMBER *
Your answer
Adult Contact EMAIL (please check this email regularly as this will be a primary form of communication) *
Your answer
Address: *
Your answer
Name of Student for Earn-a-Bike program *
Your answer
Age of Student for Earn-a-Bike program *
Required
Student Gender Identification *
Your answer
Student Approximate Height (feet, inches) *
Your answer
Scholarship & Fee Options
At Open Roads we welcome any student to participate in programs. We have generous donors who have made a FULL SCHOLARSHIP 100% possible for ANY student. The suggested fee for this six week program is $150. With this knowledge, please indicate the financial support the student(s) you are registering may require:
Financial Support *
Submit
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