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Child Information
Child's Name
First Last
Child's Date of Birth
Date Format: MM slash DD slash YYYY
Social Security Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent Information
Father's Name
First Last
Father's Phone
Mother's Name
First Last
Mother's Phone
Best email address to use to contact you
Parent Address (If Different from Child)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Are the Parents the Primary Caretakers of the Child?
Does Child live at home with parents?
Father's Employment Status
Mother's Employment Status
Additional Notes on financial or employment status:
Child's Disability Information
Child Disability
Length of Time of disability or condition:
Extend of limitations or dysfunction
How is the child's care funded at present?
Total annual income of parents or individual/group providing child's care?
Equipment/Services
How did you hear about Pedaling for Kids?
Equipment, Item or service needed by child
Has assistance for this request been sought previously?
If yes, please provide information about previous assistance.
Applicant Information
If you are submitting this application on behalf of an child, please provide the following information.
Applicant Name
First Last
Applicant Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Applicant Phone
Applicant Email
Position/Relationship to child
Purpose of organization submitting application
If desired, please explain or add any additional comments or information that might be insightful or helpful in the application for this child
Name
This field is for validation purposes and should be left unchanged.

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Child Information

Parent Information

Child's Disability Information

Equipment/Services

Applicant Information