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Bike Buddy Program Inquiry Form
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Bike Buddy Program
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Bike Buddy Program Inquiry Form
Bike Buddy Program Inquiry Form
admin
2024-09-01T15:32:43-04:00
Bike Buddy Program Inquiry Form
Is this your first time reaching out to the Bike Buddy Program?
(Required)
Yes
No
Where did you hear about us?
(Required)
Rider Demographics
Name
(Required)
First
Last
Age
(Required)
Type of mobility impairment (please describe all that may impact riding)
(Required)
Do you have any experience with cycling before?
(Required)
Yes
No
Is your cycling experience from before or after having a mobility impairment?
Before
After
Phone
(Required)
Email
(Required)
Caregiver (“Buddy”) Information
If this section is not applicable, please select N/A.
N/A
Name
First
Last
Relation to rider
Do you have experience with cycling before?
Yes
No
Phone
Email
Availability
Please provide your general availability over the next 3 weeks. Keep in mind that the Lackawanna Heritage Valley Office hours of operation are Monday- Friday from 10 AM - 3 PM. If your availability is different from week to week, please specify.
(Required)
Who is the preferred contact for setting up a session?
(Required)
What is the preferred means of contact: please provide email or phone number.
(Required)
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