Application Explaination

Build a Bike is designed to be a fun and challenging experience. Prior bike repairing experience is not necessary for the program.

Applications are accepted on a first come first served basis. Ages 5-18 welcome. There are 25 spots open. Participants will receive their own tool kit, bike helmet, virtual and paperback lessons, as well as a bike to repair.

ALL PARTICIPANTS ARE REQUIRED TO DONATE 4 HOURS OF SERVICE DURING THE SUMMER OF 2021.

Please take a few minutes to respond to the following questions related to the applicant’s contact info and health history. This questionnaire is required to finalize your registration, your responses will be kept  confidential, and will help determine the materials included in your enrollment packet. You MUST have a guardian sign this form.

After submitting this completed registration and application, you will be emailed by a representative from our volunteer crew to update your status on the program. If you have any questions, please email at
millerspotlight@gmail.com

Question Title

* 1. Enter Participant's Info

Question Title

* 2. How did you hear about us?

Question Title

* 3. What is the participant's birth date?

Question Title

* 4. What is the participant's age at enrollment?

Question Title

* 5. What school does the participant currently attend?

Question Title

* 6. What is your relationship to the participant?

Question Title

* 7. Camper's weight?

Question Title

* 8. Does the participant have asthma?

Question Title

* 9. Does the participant have diabetes?

Question Title

* 10. Does the participant have cardiac issues?

Question Title

* 11. Does the participant have epilepsy?

Question Title

* 12. Does the participant have a bleeding, or blood disorder?

Question Title

* 13. If yes please specify condition.

Question Title

* 14. Does the participant have current orthopedic (bone/ joint) issues?

Question Title

* 15. If yes please describe.

Question Title

* 16. Does the participant have been in counseling within the past year?

Question Title

* 17. If yes, what is/ was being addressed?

Question Title

* 18. Does the participant take any medications?

Question Title

* 19. Please list any medications that the participant is currently taking.

Question Title

* 20. Does the participant have any allergies that require the use of an EpiPen, cause hives or difficulty breathing?

Question Title

* 21. Is there anything else that would be helpful for the Ken Parr Build a Bike crew to know that has not been asked?

Question Title

* 22. If yes, please explain:

Question Title

* 23. Participant's Guardian's Info

Question Title

* 24. What is your relationship to the camper?

Question Title

* 25. Do you confirm that the participant will donate 4 hours of service to the help the community complete a service project this summer?

T