Earn-A-Bike Application

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Application

We are delighted that you are interested in applying for the Earn-A-Bike program, and we are glad to have you join our community of dedicated cyclists. After completing this form and paying the $20 fee, you will receive an email with a link to our online calendar where you can sign up for your EAB Volunteer shifts and Workshops.

Earn-A-Bike is open to low-income applicants 13 years and older who do not own a bike in good repair.

A SAFE AND RELIABLE BIKE WILL BE CHOSEN FOR YOU BASED ON YOUR HEIGHT. EXPECT A BEACH CRUISER TYPE OF BIKE. TYPICALLY WITH ONE GEAR AND PNEUMATIC TIRES. You will receive a membership, lock, helmet, and light if available. We currently do have a waiting list for bicycles. All communication should be through manager@communitycycles.org.

Name

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

Home Phone

Phone

I do not have a phone

Height*

Weight*

EAB Status

Campaign

Date

Emergency Contact Name

First Name

Last Name

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Email

Emergency Contact Email - Copy

Current Travel Habits

How many miles do you currently travel on the average day?*

1-3 Miles 4-6 Miles 7-10 Miles 11-20 Miles 21+ Miles

How often do you use the following modes of transportation?*

How often do you use the following modes of transportation?
	Every Day	Most Days	Some Days	Never
Drive car	How often do you use the following modes of transportation?: Drive car (Every Day)	Drive car (Most Days)	Drive car (Some Days)	Drive car (Never)
Carpool	Carpool (Every Day)	Carpool (Most Days)	Carpool (Some Days)	Carpool (Never)
Bus	Bus (Every Day)	Bus (Most Days)	Bus (Some Days)	Bus (Never)
Taxi	Taxi (Every Day)	Taxi (Most Days)	Taxi (Some Days)	Taxi (Never)
Walk	Walk (Every Day)	Walk (Most Days)	Walk (Some Days)	Walk (Never)
Bike	Bike (Every Day)	Bike (Most Days)	Bike (Some Days)	Bike (Never)

How will you use the bike you earn?*

Work / Workforce Training To look for work Errands School Recreation Meetings/Social Activities

Check all that apply.

What would encourage you to ride a bike more?*

Knowing the rules of the road Understanding my rights as a cyclist Improving my riding skills Knowing routes to ride Having people to ride with Knowing how to put my bike on the bus Having a safe place to store my bike Being able to carry things on my bike (groceries, gear, etc) Knowing how to bike with my child(ren) or companion animal

Check all that apply.

Earn-A-Bike Program Fee

The Earn-A-Bike program fee is $20.

Thanks for your financial contribution to our program. With your support, we are getting more folks on bikes in our community!

Your Annual Income must not exceed the following amount for your household size

1 person - $32,760

2 persons - $37,440

3 persons - $42,120

What best describes your income relative of the Area Median Income (AMI)? See chart below.*

under 30% AMI under 50% AMI under 80% AMI Over 80% AMI

Area Median Income (AMI) for a Household in Boulder County

If outside of Boulder County, please refer to this chart.

	AMI	1 Person	2 people	3 people	4 people	5 people	6 people	7 people	8 people
Boulder County	30%	$26350	$30100	$33850	$37600	$40650	$43650	$46650	$49650
Boulder County	50%	$43900	$50200	$56450	$62700	$67750	$72750	$77750	$82800
Boulder County	80%	$63000	$72000	$81000	$89950	$97150	$104350	$111550	$118750

EAB fee

Total $

The program includes: 6 hours of volunteer time, up to 2 classes on bike mechanics, a single speed bike and a membership with Community Cycles, U-lock , and helmet (if available). Thanks for your participation! Together, we getting more people on bikes.

Social Services Referral Discount

DiscountCode

If given a discount code, enter it here and click "Apply Discount"

Name on Card*

First Name

Last Name

Credit Card*

By Clicking the Submit Form, You agree to complete all EAB requirements within 30 days. Your application form is complete AFTER you select submit. You will receive an email shortly that will give you a link to sign up for your Earn-A-Bike classes and Volunteer shifts!

Application

Support from Social Service Agencies

Demographic Information

Current Travel Habits

Earn-A-Bike Program Fee

Area Median Income (AMI) for a Household in Boulder County