Join the Pedal Ahead Movement! Name* First Last Occupation*EmployedUnemployedRetiredStudentOtherDate of Birth* Email* Street Address* Phone*Zip Code* Personal Reference:* Reference Phone*Reference Email* Primary Transportation Need: Work Work Search School Everyday Transportation Frequency of Use: Everyday Connect to public transportation Number of family members in household:Note: One Pedal Ahead e-bike allowed per householdWhat is your bicycle riding experience?BeginnerNoviceExperiencedAre you willing to: Participate in monthly meetings at Uptown Bicycles, 3437 Adams Avenue, Normal Heights, our headquarters for training, meetings and group rides. Be trained on technical skills – bicycle maintenance Be trained on business operations Do small group ride on a regular basis (once a month) Commit to a 2 year agreement, and share trip data with Pedal Ahead. RSV does not release respondents' information. PROGRAM REQUIREMENT: Secure low cost bicycle insurance that covers liability, loss, theft and damage to the Pedal Ahead e-bike. Sign up for the Pedal Ahead monthly newsletter spotlighting program news, information, events and rides; and tips on e-bike operation and maintenance. What would you use an electric bicycle for, check all that apply: To replace car trips Health – a medical condition reduced my ability to ride a standard bicycle Health – to increase fitness To ride with less effort To be able to keep up when riding with friends/family To carry cargo or kids It’s a cost effective form of transportation To start cycling or to cycle more often To ride longer distances to places I need to go To avoid traffic in my car To avoid parking hassles in my car For environmental reasons For recreation purposes Annual income:*$0$1 to $9,999$10,000 to $24,999$25,000 to $49,999$50,000 to $74,999$75,000 to $99,999$100,000 to $149,999$150,000 and greaterPrefer not to answer(Which of these describes your personal income last year?)Driver’s License number: What Percentage of Your Trips are By Car?0%10%20%30%40%50%60%70%80%90%100%What Percentage of Your Trips are by Standard Bicycle?0%10%20%30%40%50%60%70%80%90%100%What Percentage of Your Trips are By Public Transportation?0%10%20%30%40%50%60%70%80%90%100%What Percentage of Your Trips are Walking?0%10%20%30%40%50%60%70%80%90%100%Are you a member of a community organization Yes No Organization name Any additional feedback?Where did you hear about the program: CAPTCHAUntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledFirst ChoiceSecond ChoiceThird Choice Return to Homepage
