Apply Online - Pedals of Hope

Please fill out the form below to apply for an adaptive bike through Pedals of Hope. All information is kept confidential and used only to evaluate your application.

A parent, guardian, or therapist may complete this form on behalf of the child. Fields marked with * are required.

Child Information

Child's First Name *

Child's Last Name *

Date of Birth *

Gender

Height (inches) *

Weight (lbs) *

Parent / Guardian Information

Parent/Guardian Full Name *

Relationship to Child *

Email *

Phone *

Street Address *

City *

State *

ZIP Code *

Medical Information

Primary Diagnosis / Condition *

Secondary Conditions (if any)

Brief Description of Mobility Challenges *

Current Mobility Aids Used

Can the child pedal with their feet? *

Can the child steer / use hand brakes? *

Does the child need trunk / lateral support? *

Referring Provider

A letter of medical necessity from a therapist or physician is required. You can upload or email it separately to pedalsofhopeorg@gmail.com.

Provider Name *

Provider Type *

Practice / Facility Name

Provider Phone

Provider Email

Equipment Preferences

Type of Equipment Interested In *

Has the child tried adaptive cycling before?

Goals for Cycling

Financial Information

Financial need is a factor but never a barrier. We use a sliding scale and work with every family.

Do you need financial assistance? *

Insurance Provider (optional)

Existing Funding Source or Grant (optional)

Additional Information

How did you hear about Pedals of Hope?

Preferred Location *

Additional Notes or Comments

I confirm that the information provided is accurate and I authorize Pedals of Hope to contact the referring provider listed above. I understand that submitting this form does not guarantee approval and that a letter of medical necessity is required. *

🔒 Your information is sent securely and kept confidential.
We’ll reach out within about a week after receiving your application.

What Happens Next?

After submitting your application, our team will review it and reach out to you. Please email your child's letter of medical necessity to pedalsofhopeorg@gmail.com, include your child's name in the subject line. Questions? Call us at (248) 707-0136.

Online Registration

2026 applications are full

What Happens Next?