Referral Form for Pedal Gives Back in H&F

First name

Last name

Age range

Phone number

First part of their home postcode?

Do they rent or own their home?

Which of the following benefit are they in receipt of (must be at least one; must also be able to provide proof with their name and address clear):

Tell us a little more about how a bicycle would make a difference to the person's day to day activities, giving as much detail as possible.

Using a bicycle that is too small or too big could prompt uneasiness, pain, and injury, so we need to know accurate height of the person who needs the bike. They can measure this by standing on the floor with shoes off and back up against the wall, and measuring from the base of your feet to the apex point of the head. It might help to have some assistance, if safely possible.

Does the person know what type of frame they need? (Note that a step-through is typically the easier to board option for those who might struggle or are less flexible than they once were.)

Organisation name

What theme do you cover, with reference to this person you’re referring?

What population type do you cover, with reference to this person you’re referring? (Tick as many as apply)

If we find a match for a bike, who is the best person to contact at your organisation? Please provide full name, role title, email and direct phone number.