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2. Please complete your contact details. *
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3. Are you male or female? *
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4. What is your age? Please note that you must be over 16 to be loaned a bike. If under 18 a parent or guardian will need to sign and provide financial guarantees. *
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5. What is your employment status? *
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6. What is your approximate height? *
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7. What is your approximate weight? *
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8. Please select the type of bike you would like to try. All our bikes are suitable for riding on roads, through parks and on firmed tracks. All bikes are fitted with mudguards, rear luggage carrier, and are equipped with a lock. Images shown on the website are to provide an indication of style of bike, the actual bike loaned may differ from the image. *
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9. Was this scheme recommended to you, or were you referred to us by an agency or organisation? *
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10. What best describes your level of cycling competence? *
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11. What are the main reason/s for loaning a bike? Please tick all that apply. *
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12. In a typical week, how many days do you travel to education, training or work using these as your MAIN mode of transport? (i.e. for the longest part of your journey).
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13. In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate?
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14. Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? *
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15. How did you hear about the scheme? *
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16. Occasionally we will be looking for people take part in a case study for this scheme. This may include being interviewed, having your photo taken or taking part in a video. On this basis would you be willing to take part in a case study? *
You must agree to this question to take part in the Forward Motion Bike Loan Scheme
17. The information and/or personal data you have given us is collected on behalf of SEAT (South Essex Active Travel) – as our service is offered as part of this partnership. We will only use the data you have supplied to provide you with travel advice and services, and to monitor the quality and effect of our services. To do this we may share your data with other partners in the SEAT partnership. All SEAT data sharing and processing is done under the auspices of Southend-on-Sea Borough Council – a data controller registered with the Information Commissioner’s Office.
I agree that you can share my contact details within the SEAT partnership for the purposes of providing travel advice and services, and monitoring the quality and effect of these services
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