Borrow-a-Bike Request:  Referral Form
COMMUNITY BIKE CENTRE
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ELIGIBILITY
Please check one or more sub-categories that may apply to the applicant. Please be advised that you may be required to furnish proof of eligibility under appropriate category or sub-category. *
Required
REFERRAL DECLARATION
To be signed by the referring Agency
I certify that the applicant is an existing client of / student of:  (specify AGENCY below)
i) I am aware that the Community Bike Centre (CBC) is a project operated by the Community Environment Alliance (CEA) with an aim to connect people with bikes to better their lives.  ii) I understand that CEA ultimately reserves the right to determine eligibility of recipients based on the applicant’s need and availability of bikes. iii) I certify all information given by the applicant is true and accurate to the best of my knowledge at the time of this application.
Referee First and Last name
Title
Date
Phone number
RECIPIENT INFORMATION
First and Last name: *
Address: *
City: *
Province: *
Postal code: *
Email: *
Phone number: *
Gender: *
Age group:
Clear selection
Height (ft) (This information will be used to match a bicycle)
Details
Employment status: *
Annual family income: *
Do you own a bicycle? *
If yes, justify why you need another one.
If not, how do you commute presently for your needs?
What would you use the bicycle for?  Check all that apply. *
Required
Please tell us about your biking skills: *
If you are applying under “Student” category please check your current enrollment status.
Clear selection
Tell us in what ways a bike will improve your quality of life: *
Borrow-a-Bike Program Guidelines
Please read these terms and conditions carefully:

1. Borrow-A-Bike program is based on an eligibility criteria and availability of bikes.

2. The bikes are loaned monthly, with a possibility of renewal based on availability. The bike and associated equipment will be inspected and maintained between each loan period by CBC.

3. Community Bike Centre membership is available for individuals 15 years and older for a nominal annual fee ($10).  Membership is required to participate in the Borrow-a-Bike program.  When you become member, you are supporting a healthier environment and programs to promote biking and biking resources in the community. You also receive perks including free bike tune ups and access to biking information and resources!

4. Bikes must be returned by 12 pm on day of return.

5. CBC will adjust the bike before the loan period begins, however it is your responsibility to ensure that the bike is in proper working order before you use the bike; this includes brakes, steering, tires, and drive shaft including pedals.

6. A security deposit of $100 is required for adult bikes and $50 for small bikes (sliding scale is available based on eligibility) is required when taking the bike. The deposit will be returned upon return of the bike in a satisfactory condition.

7. You will be held financially liable for any repairs, loss or damage to the bike.

8. Report any loss of bicycle immediately to the police and CBC at 905-463-9941. Please provide a copy of the police report to CBC.

9. You shall not sell, charge assign, lease or otherwise dispose of the bike.

10. For your safety we strongly recommend you always wear a helmet while riding a bike.

11. You must use the bike in accordance with the Ontario's Highway Traffic Act (HTA) and all applicable laws and bylaws including use of proper reflectors and bicycle lights.

12. You must always lock the bike to a fixed object when unattended.

13. You must not ride the bike or allow it to be ridden if it is faulty or defective. If any problems are noticed then this should be reported to CBC at 905-463-9941 immediately.

14.  By participating in the Borrow-a-Bike Program, the kilometers biked during the loan duration will be contributed to the Bike4Brampton Campaign.
APPLICANT DECLARATION
To be signed by the applicant or authorized person upon submission of application.  By submitting this application:
I or parent/ guardian (if participant is a minor-under the age of 18) confirm to have read, understood and agree to the guidelines of borrowing a bike under the Community Bike Centre: Borrow-A-Bike program. *
Required
I or parent/ guardian understand that borrowing a bike is based on eligibility criteria and availability of bikes. *
Required
I or parent/ guardian understand that to participate in the Borrow-a-Bike Program:  i) a Community Bike Centre membership is required ($10 annual membership fee) and ii) a security deposit of $100 is required for adult bikes and $50 for small bikes (sliding scale is available based on eligibility) is required when taking the bike (which will be returned upon return of the bike).  I understand I need to sign a waiver before borrowing the bike. *
Required
Disclaimer for Privacy
The information that you have provided is collected in accordance with Community Environment Alliance’s (CEA) Privacy
Policy, which has been created for compliance with Canada's Personal Information Protection and Electronic Documents
Act (PIPEDA) and Ontario's Personal Information Protection Act (PIPA). By providing your personal information on this
form, you are consenting to the collection of this information in order for CEA to better tailor client services. You may
request access to this stored information at any time, in accordance with CEA’s Privacy Policy. Please note that
Community Environment Alliance retains your consent until you withdraw it in writing.

CEA is committed to protecting personal information and does not sell trade or exchange personal information with third
parties.
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