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Recipient Information Form

Please fill the following form out to submit information about a child. Again, we are looking for children ages 5-15 years old that have landed in less than fortunate circumstances, divorced and or single parent families and kids in foster homes, and/or children who have fallen ill to life threatening diseases and who have overcome them. Please fill in as many of the fields as possible, it makes our job easier!


 
First Name
Last Name
Age of Child
Child's Street Address
City
State
Zip
Name of parent/guardian if available.
Parent/Guardian Phone #
Bike size will be determined by age of child.
We will only ship in the U.S.
Additional Comments