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PARTICIPANT INTAKE FORM


Today's Date: March 10, 2026

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
Information
Diagnosis
Level of Disability for transfers (check only 1) *
Independent
Supervision
Minimal Assistance (subject=75% or more)
Moderate Assistance (subject = 50% or more)
Maximal Assistance(subject=25% or more)
Total Assistance
Daily attitude/general disposition (circle number most appropriate on scale)*
Fear of Movement*
Can participant verbally communicate? *
No
Yes
If NO to Question 10, describe mode of communication
Can participant follow basic safety instructions? *
No
Yes
Height
Weight (250 pound maximum allowed)
Inseam length in inches (to adjust cycle length – crotch to bottom of heel)
Shirt Size (adult size)
XS
S
M
L
XL
Helmet size *
XS (below 20” head circumference)
S (20”-21.75” head circumference)
M (21.75”-23.25” head circumference)
L (23.25”-24.75” head circumference)
XL(above 24.75” head circumference)
Any previous cycling experience?
No
Yes
Other recreational activities currently participating in: (please list)
Level of interest in participating in cycling (circle number most appropriate on scale)*
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Diagnosis
Level of Disability for transfers (check only 1) *
Independent
Supervision
Minimal Assistance (subject=75% or more)
Moderate Assistance (subject = 50% or more)
Maximal Assistance(subject=25% or more)
Total Assistance
Daily attitude/general disposition (circle number most appropriate on scale)*
Fear of Movement*
Can participant verbally communicate? *
No
Yes
If NO to Question 10, describe mode of communication
Can participant follow basic safety instructions? *
No
Yes
Height
Weight (250 pound maximum allowed)
Inseam length in inches (to adjust cycle length – crotch to bottom of heel)
Shirt Size (adult size)
XS
S
M
L
XL
Helmet size *
XS (below 20” head circumference)
S (20”-21.75” head circumference)
M (21.75”-23.25” head circumference)
L (23.25”-24.75” head circumference)
XL(above 24.75” head circumference)
Any previous cycling experience?
No
Yes
Other recreational activities currently participating in: (please list)
Level of interest in participating in cycling (circle number most appropriate on scale)*
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Diagnosis
Level of Disability for transfers (check only 1) *
Independent
Supervision
Minimal Assistance (subject=75% or more)
Moderate Assistance (subject = 50% or more)
Maximal Assistance(subject=25% or more)
Total Assistance
Daily attitude/general disposition (circle number most appropriate on scale)*
Fear of Movement*
Can participant verbally communicate? *
No
Yes
If NO to Question 10, describe mode of communication
Can participant follow basic safety instructions? *
No
Yes
Height
Weight (250 pound maximum allowed)
Inseam length in inches (to adjust cycle length – crotch to bottom of heel)
Shirt Size (adult size)
XS
S
M
L
XL
Helmet size *
XS (below 20” head circumference)
S (20”-21.75” head circumference)
M (21.75”-23.25” head circumference)
L (23.25”-24.75” head circumference)
XL(above 24.75” head circumference)
Any previous cycling experience?
No
Yes
Other recreational activities currently participating in: (please list)
Level of interest in participating in cycling (circle number most appropriate on scale)*
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Diagnosis
Level of Disability for transfers (check only 1) *
Independent
Supervision
Minimal Assistance (subject=75% or more)
Moderate Assistance (subject = 50% or more)
Maximal Assistance(subject=25% or more)
Total Assistance
Daily attitude/general disposition (circle number most appropriate on scale)*
Fear of Movement*
Can participant verbally communicate? *
No
Yes
If NO to Question 10, describe mode of communication
Can participant follow basic safety instructions? *
No
Yes
Height
Weight (250 pound maximum allowed)
Inseam length in inches (to adjust cycle length – crotch to bottom of heel)
Shirt Size (adult size)
XS
S
M
L
XL
Helmet size *
XS (below 20” head circumference)
S (20”-21.75” head circumference)
M (21.75”-23.25” head circumference)
L (23.25”-24.75” head circumference)
XL(above 24.75” head circumference)
Any previous cycling experience?
No
Yes
Other recreational activities currently participating in: (please list)
Level of interest in participating in cycling (circle number most appropriate on scale)*
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Diagnosis
Level of Disability for transfers (check only 1) *
Independent
Supervision
Minimal Assistance (subject=75% or more)
Moderate Assistance (subject = 50% or more)
Maximal Assistance(subject=25% or more)
Total Assistance
Daily attitude/general disposition (circle number most appropriate on scale)*
Fear of Movement*
Can participant verbally communicate? *
No
Yes
If NO to Question 10, describe mode of communication
Can participant follow basic safety instructions? *
No
Yes
Height
Weight (250 pound maximum allowed)
Inseam length in inches (to adjust cycle length – crotch to bottom of heel)
Shirt Size (adult size)
XS
S
M
L
XL
Helmet size *
XS (below 20” head circumference)
S (20”-21.75” head circumference)
M (21.75”-23.25” head circumference)
L (23.25”-24.75” head circumference)
XL(above 24.75” head circumference)
Any previous cycling experience?
No
Yes
Other recreational activities currently participating in: (please list)
Level of interest in participating in cycling (circle number most appropriate on scale)*
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Diagnosis
Level of Disability for transfers (check only 1) *
Independent
Supervision
Minimal Assistance (subject=75% or more)
Moderate Assistance (subject = 50% or more)
Maximal Assistance(subject=25% or more)
Total Assistance
Daily attitude/general disposition (circle number most appropriate on scale)*
Fear of Movement*
Can participant verbally communicate? *
No
Yes
If NO to Question 10, describe mode of communication
Can participant follow basic safety instructions? *
No
Yes
Height
Weight (250 pound maximum allowed)
Inseam length in inches (to adjust cycle length – crotch to bottom of heel)
Shirt Size (adult size)
XS
S
M
L
XL
Helmet size *
XS (below 20” head circumference)
S (20”-21.75” head circumference)
M (21.75”-23.25” head circumference)
L (23.25”-24.75” head circumference)
XL(above 24.75” head circumference)
Any previous cycling experience?
No
Yes
Other recreational activities currently participating in: (please list)
Level of interest in participating in cycling (circle number most appropriate on scale)*
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Diagnosis
Level of Disability for transfers (check only 1) *
Independent
Supervision
Minimal Assistance (subject=75% or more)
Moderate Assistance (subject = 50% or more)
Maximal Assistance(subject=25% or more)
Total Assistance
Daily attitude/general disposition (circle number most appropriate on scale)*
Fear of Movement*
Can participant verbally communicate? *
No
Yes
If NO to Question 10, describe mode of communication
Can participant follow basic safety instructions? *
No
Yes
Height
Weight (250 pound maximum allowed)
Inseam length in inches (to adjust cycle length – crotch to bottom of heel)
Shirt Size (adult size)
XS
S
M
L
XL
Helmet size *
XS (below 20” head circumference)
S (20”-21.75” head circumference)
M (21.75”-23.25” head circumference)
L (23.25”-24.75” head circumference)
XL(above 24.75” head circumference)
Any previous cycling experience?
No
Yes
Other recreational activities currently participating in: (please list)
Level of interest in participating in cycling (circle number most appropriate on scale)*
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Diagnosis
Level of Disability for transfers (check only 1) *
Independent
Supervision
Minimal Assistance (subject=75% or more)
Moderate Assistance (subject = 50% or more)
Maximal Assistance(subject=25% or more)
Total Assistance
Daily attitude/general disposition (circle number most appropriate on scale)*
Fear of Movement*
Can participant verbally communicate? *
No
Yes
If NO to Question 10, describe mode of communication
Can participant follow basic safety instructions? *
No
Yes
Height
Weight (250 pound maximum allowed)
Inseam length in inches (to adjust cycle length – crotch to bottom of heel)
Shirt Size (adult size)
XS
S
M
L
XL
Helmet size *
XS (below 20” head circumference)
S (20”-21.75” head circumference)
M (21.75”-23.25” head circumference)
L (23.25”-24.75” head circumference)
XL(above 24.75” head circumference)
Any previous cycling experience?
No
Yes
Other recreational activities currently participating in: (please list)
Level of interest in participating in cycling (circle number most appropriate on scale)*
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Diagnosis
Level of Disability for transfers (check only 1) *
Independent
Supervision
Minimal Assistance (subject=75% or more)
Moderate Assistance (subject = 50% or more)
Maximal Assistance(subject=25% or more)
Total Assistance
Daily attitude/general disposition (circle number most appropriate on scale)*
Fear of Movement*
Can participant verbally communicate? *
No
Yes
If NO to Question 10, describe mode of communication
Can participant follow basic safety instructions? *
No
Yes
Height
Weight (250 pound maximum allowed)
Inseam length in inches (to adjust cycle length – crotch to bottom of heel)
Shirt Size (adult size)
XS
S
M
L
XL
Helmet size *
XS (below 20” head circumference)
S (20”-21.75” head circumference)
M (21.75”-23.25” head circumference)
L (23.25”-24.75” head circumference)
XL(above 24.75” head circumference)
Any previous cycling experience?
No
Yes
Other recreational activities currently participating in: (please list)
Level of interest in participating in cycling (circle number most appropriate on scale)*
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Diagnosis
Level of Disability for transfers (check only 1) *
Independent
Supervision
Minimal Assistance (subject=75% or more)
Moderate Assistance (subject = 50% or more)
Maximal Assistance(subject=25% or more)
Total Assistance
Daily attitude/general disposition (circle number most appropriate on scale)*
Fear of Movement*
Can participant verbally communicate? *
No
Yes
If NO to Question 10, describe mode of communication
Can participant follow basic safety instructions? *
No
Yes
Height
Weight (250 pound maximum allowed)
Inseam length in inches (to adjust cycle length – crotch to bottom of heel)
Shirt Size (adult size)
XS
S
M
L
XL
Helmet size *
XS (below 20” head circumference)
S (20”-21.75” head circumference)
M (21.75”-23.25” head circumference)
L (23.25”-24.75” head circumference)
XL(above 24.75” head circumference)
Any previous cycling experience?
No
Yes
Other recreational activities currently participating in: (please list)
Level of interest in participating in cycling (circle number most appropriate on scale)*
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Diagnosis
Level of Disability for transfers (check only 1) *
Independent
Supervision
Minimal Assistance (subject=75% or more)
Moderate Assistance (subject = 50% or more)
Maximal Assistance(subject=25% or more)
Total Assistance
Daily attitude/general disposition (circle number most appropriate on scale)*
Fear of Movement*
Can participant verbally communicate? *
No
Yes
If NO to Question 10, describe mode of communication
Can participant follow basic safety instructions? *
No
Yes
Height
Weight (250 pound maximum allowed)
Inseam length in inches (to adjust cycle length – crotch to bottom of heel)
Shirt Size (adult size)
XS
S
M
L
XL
Helmet size *
XS (below 20” head circumference)
S (20”-21.75” head circumference)
M (21.75”-23.25” head circumference)
L (23.25”-24.75” head circumference)
XL(above 24.75” head circumference)
Any previous cycling experience?
No
Yes
Other recreational activities currently participating in: (please list)
Level of interest in participating in cycling (circle number most appropriate on scale)*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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