Finding Balance Intake Form Question Title * 1. Contact Information Name City/Town Email Address Phone Number OK Question Title * 2. Funding for this pilot program requires that we prioritize participants from the following populations: youth 19-29, people of low income or living in poverty, Indigenous, Newcomer, women and girls, and/or essential workers. Do you identify with one of these? (If no, please still fill in the rest of the application and we'll be in touch.) Yes No OK Question Title * 3. How would you describe your experience level? I have not yet learned to ride a bike. I haven't ridden a bike in years. I can ride a bike, but do not feel confident braking and manoeuvring. I can ride a bike, but stick to trails. I don't feel confident on the roads. OK Question Title * 4. How would you rate your comfort level with the following: (1 = no comfort, 5 = very comfortable) 1 2 3 4 5 Getting on and off a bike Getting on and off a bike 1 Getting on and off a bike 2 Getting on and off a bike 3 Getting on and off a bike 4 Getting on and off a bike 5 Balancing while riding forward Balancing while riding forward 1 Balancing while riding forward 2 Balancing while riding forward 3 Balancing while riding forward 4 Balancing while riding forward 5 Stopping with control Stopping with control 1 Stopping with control 2 Stopping with control 3 Stopping with control 4 Stopping with control 5 Riding in a straight line Riding in a straight line 1 Riding in a straight line 2 Riding in a straight line 3 Riding in a straight line 4 Riding in a straight line 5 Managing turns Managing turns 1 Managing turns 2 Managing turns 3 Managing turns 4 Managing turns 5 Riding with one hand Riding with one hand 1 Riding with one hand 2 Riding with one hand 3 Riding with one hand 4 Riding with one hand 5 Riding on the road Riding on the road 1 Riding on the road 2 Riding on the road 3 Riding on the road 4 Riding on the road 5 OK Question Title * 5. What is your motivation for taking this course? OK Question Title * 6. What do you hope to learn from this course? OK Question Title * 7. Is there anything that we should know about you as a learner, including anything about cycling that causes you worry? OK Question Title * 8. Do you have any of the following gear? (Note: We can supply all of these items. This questions is just to ask if you want to use your own gear.) Bike Helmet Bike lock OK Question Title * 9. Do you have any questions for us? OK Thank you for applying! We will be in touch soon. OK Question Title OK DONE