Bikes Without Barriers Application

Please complete the following application as accurately as possible to ensure the fastest response. Please ensure that a current phone and email address are included, so we can contact you to discuss the next step toward getting your adaptive bike.

Please be advised that our Bikes Without Barriers Program is based in Huntington, WV.  We serve children and adults with disabilities in the tri-state area, so applicants must be within a reasonable distance to either pickup or deliver their final bike.

Recipient's Name(Required)
MM slash DD slash YYYY
Parent/Guardian Name(Required)
What is the best way to contact you? (Please check all that apply)(Required)

Address(Required)
How did you hear about the Bikes Without Barriers?(Required)

Will you need financial assistance to obtain the adaptive bike? (Financial aid is not guaranteed. We are constantly working with our partner organizations and donors to secure additional funding for the program. Often families fully fund their bikes with a variety of methods, including self-pay, peer-to-peer fundraising, local grants, and other resources in addition to our efforts to help secure funding.)
Do you have access to waiver funding?(Required)
*This information will be made public to help obtain funding for your bike. Please don't include information you don't want shared on social media, with potential funders, etc.
*By including a photo, you are giving consent to Developmental Therapy Center to use the image online and in print to help obtain funding.
Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.
Recipient's History of Biking(Required)
What have you ridden in the past - regular two-wheel bike, adaptive trike, etc.? Do you ride regularly at school?
Will you need an interpreter?