Organization name:
Referring staff member name:
Referring staff member email:
Referring staff member phone:
Client first name and last initial:
Client age:
Client height:
Client weight:
Where does the individual live (City or Town only)?
How many days/week will the bike be used?
How many miles does the individual need to travel on a typical day?
Does the individual have any physical limitations we need to be aware of (inability to lift leg over a bike frame, limited balance, etc.)?
Are there any other specific requests from the individual about the bike or any other things we should know about the individual's need?
