Pedal Ahead Sign Up – Pedal Ahead

Name*

First Last

Occupation*

Name of Employer (Business)

Position at Work*

Date of Birth*

Email*

Street Address*

Phone*

Zip Code*

Personal Reference:*

Reference Phone*

Reference Email*

Frequency of Use:

Everyday
Connect to public transportation

Number of family members in household:

Note: One Pedal Ahead e-bike allowed per household

What is your bicycle riding experience?

Please list your height

Are 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:

Annual income:*

(Which of these describes your personal income last year?)

Driver’s License number:

What Percentage of Your Trips are By Car?

What Percentage of Your Trips are by Standard Bicycle?

What Percentage of Your Trips are By Public Transportation?

What Percentage of Your Trips are Walking?

Are you a member of a community organization

Yes
No

Organization name

Any additional feedback?

Where did you hear about the program:

I agree to mileage requirements of averaging 5 miles/day, 35 miles/wk or 140 a month*

Yes

I acknowledge failure to sustain mileage requires returning the bicycle for re-allocation

Yes

I agree to sign a liability waiver for any party to indemnify, defend and hold the other party(s) harmless from any claims or damages to anyone with responsibilities under the program; and from any negligence, errors or omissions by any directors, officers, employees, subcontractors or agents of the Indemnifying Party.

Yes

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