MedStar NRH Adaptive Cycling Interest Survey
Thank you for your interest in MedStar National Rehabilitation Hospital's Adaptive Cycling Program. We are looking to gather some information from potential participants in order to begin scheduling programming soon. For specific questions, concerns or suggestions, please e-mail Lizzy Parker at Elizabeth.V.Parker@medstar.net

*****All of our programming will be structured to strictly follow COVID-19 protocols and guidelines.*****
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First and Last Name *
Date of Birth
DD
/
MM
/
YYYY
Email Address *
Address
Phone number
What is your means of transportation?
What day(s) of the week would you prefer to attend programming?
What time of day would you prefer to attend programming?
What level of assistance would you require to transfer for uneven levels?
What level cyclist do you consider yourself?
Do you have your own adaptive cycle?
Are you interested in attending an Adaptive Cycling clinic? (1 to 1 instruction, scheduled time slot, track/shorter trail-based rides).
Clear selection
Are you interested in attending Group Adaptive Cycling Meet-Ups/Rides? (Longer, trail-based rides, park meet-ups)
Clear selection
Are you interested in attending a Stationary Adaptive Cycling Class? (Similar to Spin Classes that have become popular)
Clear selection
*COVID-19 Question* At this time, would you feel comfortable attending Adaptive Cycling Programming? *All of our Programming will be structured to follow COVID-19 protocols and guidelines*
Clear selection
Do you have any other Adaptive Cycling Programming Suggestions:
Submit
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