Referral Form for Pedal Gives Back in H&F

Please note that this referral form is for the use of local groups, including charities and statutory agencies, working in Hammersmith & Fulham. Please remember that a match is not automatically guaranteed and it can take a number of months to hear back as we could get randomly acquired bikes on a monthly basis, and in varying sizes and styles.

About the person you're referring

Fname*

First name

Lname*

Last name

Date of Birth*

DD

MM

YYYY

Address*

Address (must be within Hammersmith & Fulham)

Street Address Address Line 2 ZIP / Postal Code

Does the client rent or own their home?*

Does the client rent or own their home?

Rent
Own
Other (please explain in the next question)

Household

Tell us about who they live with and about any dependents they have, including their ages.

Benefits

To ensure we reach some of the most in-need, please tell us about which benefits the person receives, including type (e.g. JSA, Housing Benefit, or Universal Credit), and amount weekly. We will ask for evidence if they are successfully matched with a bike. (Add more rows using the '+' sign to the right)

Benefit type	Weekly amount

About the bicycle the person needs

Case*

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.

Height*

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.

Frame*

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.)

Select All
Crossbar
Step-through
No preference

About your organisation

Name*

Organisation name

Reg no

Reg.charity / company no.

Organisation Website

Website / webpage link

No website qn

If you don't have a website or web link with more information, please tell us more about your organisation (including its legal structure as stated in your governing documents)

Contact for match*

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.

Submit your referral

Your name

Your role

Your role title at the organisation

Your contact email

Let us know how we can stay in touch

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Email
Phone

CAPTCHA

By submitting, you agree that the information provided is true, correct and complete to the best of your belief and knowledge.

Referral Form for Pedal Gives Back in H&F