JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Adult Bike Request Form
Complete the following form to request a no-cost bike and we will be in touch within 4 weeks. It may take us longer than this to get you a bike, but we handle requests as quickly as we can and typically in the order they are received.
Completing the form does not guarantee a bike but we will try our best to help if we can.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Is the requester eligible for a bike? We prioritize volunteer time to help currently unhoused/homeless Puebloans with bikes and bike repairs.
*
The requester is currently unhoused or homeless
The requester is not homeless but has other emergent needs (please explain in next question)
Please tell us why the requester needs a bike if you answered "The requester is not homeless but has other needs" above:
Your answer
First
name of person requesting bike:
*
Your answer
Last
name of person requesting bike:
*
Your answer
Contact info so we can reach them to discuss their bike and arrange a pickup time (working phone and/or email):
*
Your answer
Requester height so we can size a bike (best guess is ok,
please select only 1 box
):
0-2 inches
3-5 inches
6-8 inches
9-11 inches
4 foot
5 foot
6 foot
0-2 inches
3-5 inches
6-8 inches
9-11 inches
4 foot
5 foot
6 foot
Requester weight so we can size a bike and pick the right tires (best guess is ok):
*
90-120lbs
120-150lbs
150-180lbs
180-210lbs
210-240lbs
240lbs+
Required
Do you require any special type of bicycle to use one safely? (tricycle, step-through, recumbent, etc)
*
No, a regular bike is fine
Yes, I need a special bike because of mobility limitations or other reasons (answer next question if so)
If you need a special type of bike, please explain your need and we'll try our best to help meet it. It may take us longer to get you a bike, though. What kind of special bike do you need?:
Your answer
Do you have a working bike lock?
If not, you will need to bring
$5
with you when you pick up your bike to purchase one from GCBB.
We will
NOT
send a bike out without a lock! Yours or ours does not matter, but a working lock
must
go with the bike.
*
I acknowledge I need to either bring a working lock with me OR bring $5 cash to buy one.
Anything else we need to know to help you with a bike?
Your answer
Name and Agency/Organization of person completing this referral form (Name, Agency):
*
Your answer
Thanks! We'll be in touch soon.
Please enter today's date below to compete the request.
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
