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!

Students ages 10 to 15 are eligible to be registered and they must commit to attending five of the six sessions Earn-a-Bike sessions in order to earn their bike.

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 16-18 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 "Financial Support" 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 *
(If Applicable) Please explain why your student requires a scholarship to complete this program.:
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Open Roads Bike Program. Report Abuse - Terms of Service