APPLICATION FOR BICYCLE OR OTHER WHEELED TOY
Please print this page, supply the following information, and return it to the address at the bottom of this form. If the child that you are applying for
qualifies, we will contact you.
Child’s Name ___________________________________________
Age
________
Birthday _______________________________ (We will send B-day cards)
Gender ___Male ___Female
Parent/Guardian Name ____________________________________
Address ________________________________________________
Telephone Number ____________________________
Email address _____________________________
Does this child have a website open to the public? If so, please specify:__________________________________________________________________
Hospital where child is treated ______________________________
Contact person at hospital _________________________________
Contact person’s telephone number or email ___________________
We may need to contact your child’s
doctor or a nurse just to confirm that their illness is considered life
threatening. No other information will be requested, nor is the
hospital permitted to release that information.
Are you requesting:(check one)
____Bicycle size 12”____ 16”____ 20”____ 24”____ 26"____
____tricycle
____Big Wheel style
____Wagon
____Other wheeled toy
If other, please specify ________________________________________________
Examples: R/C car, doll buggy, race track, pull toy, anything with wheels!
(****Note: For very young children we can supply a stroller or riding toy, etc.)
(Favorite color? (We can’t guarantee, but will try)______________)
Helmet size Infant ____ Toddler ____ Child _____ Youth _____ Other____
I agree that the above information that I have given is true and
current.
Signed _________________________________________
Date ________________________________
CODY’S WHEELS OF HOPE, Inc.
PHOTO RELEASE FORM
For Publicity Purposes:
I hereby authorize my child’s name and/or photograph to be used by Cody’s Wheels of Hope for publicity purposes to obtain donations.
I will not hold Cody’s Wheels of Hope, Inc. responsible for any unauthorized use of my child’s name and photo.
My authorization is for:
(please check one)
_____ Use of photo only
_____ Use of photo and name (only first names will be used for publicity purposes)
_____ Use of name only (only first names will be used for publicity purposes)
_____ Do not use my child’s photo or name for any publicity purposes
Child’s name: ______________________________________________
(please print)
Parent/Guardian Name: _______________________________________
(please print)
Address ___________________________________________________
(please print)
Telephone number: ____________________________________________
Signature of Parent/Guardian: __________________________________
Witness: ___________________________________ Date: ____________
CODY’S WHEELS OF HOPE, Inc.
WAIVER FORM
This bicycle/riding toy is a gift from Cody’s Wheels of Hope, Inc. We hope your child will enjoy it.
I, __________________________________________________________(Please print name)
accept this gift for ______________________________________________(Please print child’s name)
I will not hold Cody’s Wheels of Hope, Inc. responsible for any injuries or damage occurring from use of this riding vehicle.
I accept full responsibility for it’s use.
Signed ____________________________________________________
(Signature)
Date ____________________________________________________
Witness ___________________________________________________
(Signature)
Date _____________________________________________________
CODY'S WHEELS OF HOPE,Inc.
THANK YOU!!!
Thank you for your interest in a bicycle or other wheeled toy for your child. Our ONLY requirements are that the child be 15 years old or younger and have a life threatening illness.
Because many of these bikes will be shipped, you may need someone to assemble them. Helmets may be sent with them or separately.
We ask that pictures be taken of the child with his/her wheeled toy and sent to us (email or mail). Even if you do not allow us to use them for publicity, we like to see the smile of the child receiving the bike/toy.
As soon as we receive the application and signed releases, we will check the contact information and then contact you. After your child receives the bike/toy, he/she will be one of “Cody’s Friends”. If you have signed the release that allows us to use their picture and first name, they will be able to see themselves under the “Cody’s Friends” page.
Thank you for allowing us to brighten your child’s life!
Please send forms to:
Cody’s Wheels Of Hope
PO Box 8735
Erie, PA 16505