application form to receive a re-purposed bicycle
What kind of bike are you looking for?
Bike for a child ages 5-10
Bike for a child ages 11-16
Bike for a child 16+ or an adult
This bike will be used primarily for....
getting to and from school.
getting to and from work.
recreational riding (fun!).
What is your annual household income (before taxes)?
How many people live in your household (including yourself)?
Do you receive any financial assistance (TANF, WIC, SNAP, HEAP)?
None of the Above
Please read the following statements and a check the box if you agree:
I agree to take possession of a BluePrint bike for personal use by a member of my household.
I agree that I may not resell or regift a BluePrint bike.
I understand that my BluePrint bike will have unique identifying features to assist in recovery if the bike is lost or stolen.
I agree to provide any child (age 18 and under) with a suitable helmet and to require that it is worn while riding a BluePrint bike.
I agree to keep the BluePrint bike locked when not in use and to take other precautions to prevent the bike being lost or stolen.
Please provide your contact information so that we can notify you if a suitable bike is available. Let's begin with your name:
Email address and/or phone number:
Address (this program is for Geneva residents only):
Name of the person who will be riding this bike (if different than the applicant):
Never submit passwords through Google Forms.
This form was created inside of BluePrint Geneva, Inc.. -
Terms of Service