What is Spina Bifida?
About SBAAZ
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Cycle Application
General Information
Applicant's Name
Birthdate (MM/DD/YYYY)
Age
Height
Parent/Guardian Name
(If Applicant is Under 18)
Street Address
City
State
ZIP Code
Home Phone
Email
Cell/Work Phone (optional)
User Information
Has applicant ever ridden a cycle?
Yes
No
Does applicant currently have/use a cycle?
Yes
No
Does applicant have a previously awarded cycle to exchange?
Yes
No
Has applicant received a cycle from SBAAZ previously?
Yes
No
Applicant Information
Does applicant most often use a wheelchair?
Yes
No
Does applicant walk with leg braces or crutches?
Yes
No
Does applicant sit unassisted?
Yes
No
Does applicant have full use of arms?
Yes
No
Will family participate in upcoming fund raising event?
Yes
No
Placement Criteria
Is there indoor storage available for the cycle?
Yes
No
Will recipient be able to attend event to pick up cycle?
Yes
No
Have you read and will you comply with placement agreement?
Yes
No
Do you currently have renters/homeowner’s insurance?
*If you are selected to receive a cycle SBAAZ will require proof that the cycle is listed property.
Yes
No
Is family able to commit to annual use fee ($35)?
Yes
No
Please list SBAAZ events and programs your family has participated in, including the year:
How would applicant make use of this equipment if accepted into the program?
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