Pedal it Forward - We Bike Rochester
Purpose and goals:
     Provide safe and reliable bicycles to individuals in the community needing primary transportation for education, employment, and daily activities.  Encourage safe bicycling practices.  Model the life skills of self-reliance and sustainability through recycling and environmentally friendly transportation.

Applicants to receive a free bicycle may be:
Self-referred but preference will be given to those referred by a partnering organization or by a sponsor (example community social service professional or other person who can attest to the candidate’s need for a bicycle).
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Email *
Referral Source *
Applicant/Contacts Phone number *
Enter valid phone (10 digit with area code)
Applicant First Name: *
Applicant Last Name: *
Organization/Sponsor  Name:
Referral contact information will help us understand your needs and prioritize your request.
Organization/Sponsor  Email:
Referral contact email
Organization/Sponsor  Phone number:
Referral contact - Enter valid phone (10 digit with area code)
Bicycle use *
Primary purpose
Applicant essay (Please share with us how a bicycle will most benefit you personally) *
“Why I need a bicycle” (250 words or less, AI appearing responses will likely be ignored)
Age (years) *
Height (ft-in) Approximate *
Bicycle size needed
Weight  (Pounds) Approximate *
Bicycle size needed
Desired bicycle type *
Consider primary purpose and riding skills
Bicycle security (U-lock) *
I understand I will need to have in my possession a U-lock style bicycle lock or purchase one from the program for $20 (cash only) at the time I receive a bicycle in order to protect my bicycle from theft.
Bicycle safety (helmet) needed *
Bicycle helmet use is strongly recommended for your safety. If you need a helmet we will attempt to provide one if one is available.
Bicycle safety (rules) *
"I understand bicycling safety rules"
Bicycling experience (yrs)
Years of bicycling
What is your gender? *
Please Indicate the EEOC (Equal Employment Opportunity Commission) category you most closely identify with, if any: *
Required
Thank you for your interest in receiving a bicycle from our program. Your application will be reviewed and you will be notified with further details if we have a bicycle that can meet your needs.
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