SEAT Registration Form

Welcome to the Foward Motion Bike Loan Scheme.

The purpose of the scheme is to encourage more people to take up cycling by offering them the opportunity to try a bike and associated equipment to see how cycling can work for them. Priority is given to those who will be using the bike to get to work, training or education.

The scheme is to open to anyone over 16 years, who lives witihin the South Essex area within the defined postocodes detailed on the websiite.

If eligible, you will be entitled to rent a bike, lock and safety equipment.

You can also access through South Essex Active Travel free cycle training during the loan to improve your competency and confidence.

Once your registration is complete you will be contacted by an advisor within a few days to confirm your application with you.

Please answer the questions below to register for the scheme. Should you have any issues completing the form then please email info@activecyclingprojects.com.

1. Registration form

1. What is your name? *

Title	*
Full name	*

2. Please complete your contact details. *

House/ flat name or number	*
Street	*
Town	*
Postcode	*
Phone number	*
Email address	*
Confirm email address	*

3. Are you male or female? *

Male
Female
Prefer not to say
Prefer to self describe:

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. *

5. What is your employment status? *

6. What is your approximate height? *

7. What is your approximate weight? *

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. *

9. Was this scheme recommended to you, or were you referred to us by an agency or organisation? *

No
Yes (please give name of person or organisation)

10. What best describes your level of cycling competence? *

Novice or beginner- never cycled before
Unconfident returner- can cycle but not cycled for many years or still learning
Unconfident occasional- cycle a few times a year
Confident occasional- happy on a bike but don't cycle regularly
Confident regular- cycle regularly for work or leisure.

11. What are the main reason/s for loaning a bike? Please tick all that apply. *

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).
*

	0	1	2	3	4	5	6	7
Drove on my own	Drove on my own 0	Drove on my own 1	Drove on my own 2	Drove on my own 3	Drove on my own 4	Drove on my own 5	Drove on my own 6	Drove on my own 7
Travelled in a car with other people	Travelled in a car with other people 0	Travelled in a car with other people 1	Travelled in a car with other people 2	Travelled in a car with other people 3	Travelled in a car with other people 4	Travelled in a car with other people 5	Travelled in a car with other people 6	Travelled in a car with other people 7
Caught the bus	Caught the bus 0	Caught the bus 1	Caught the bus 2	Caught the bus 3	Caught the bus 4	Caught the bus 5	Caught the bus 6	Caught the bus 7
Took the train	Took the train 0	Took the train 1	Took the train 2	Took the train 3	Took the train 4	Took the train 5	Took the train 6	Took the train 7
Used Park and Ride	Used Park and Ride 0	Used Park and Ride 1	Used Park and Ride 2	Used Park and Ride 3	Used Park and Ride 4	Used Park and Ride 5	Used Park and Ride 6	Used Park and Ride 7
Walked	Walked 0	Walked 1	Walked 2	Walked 3	Walked 4	Walked 5	Walked 6	Walked 7
Cycled	Cycled 0	Cycled 1	Cycled 2	Cycled 3	Cycled 4	Cycled 5	Cycled 6	Cycled 7
Travelled by motorcycle	Travelled by motorcycle 0	Travelled by motorcycle 1	Travelled by motorcycle 2	Travelled by motorcycle 3	Travelled by motorcycle 4	Travelled by motorcycle 5	Travelled by motorcycle 6	Travelled by motorcycle 7
Travelled by taxi	Travelled by taxi 0	Travelled by taxi 1	Travelled by taxi 2	Travelled by taxi 3	Travelled by taxi 4	Travelled by taxi 5	Travelled by taxi 6	Travelled by taxi 7
	0	1	2	3	4	5	6	7

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?

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? *

No
Yes- limited a lot
Yes- limited a little

15. How did you hear about the scheme? *

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? *

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
*

Yes, I agree.