Please note that this referral form is for the use of local groups, including charities and statutory agencies, working in Hammersmith & Fulham. Please remember that a match is not automatically guaranteed and it can take a number of months to hear back as we could get randomly acquired bikes on a monthly basis, and in varying sizes and styles.

About the person you are referring

First Name *

Last Name *

Age range *
0-1112-1617-2425-3435-4445-5455+

Phone number

First line of their Home Address (must be within Hammersmith & Fulham)*

Address line 2*

Postcode*

Postcode/Reach* (First part of their home postcode)
NW10SW6SW10SW12W3W4W6W10W11W12W14

Do they rent or own their home?*
RentOwnOther(please explain in the next question)

Household - Tell us about who they live with and about any dependents they have, including their ages

Benefit Entitlement* - Which of the following benefit are they in receipt of (must be at least one; must also be able to provide proof with their name and address clear):
Universal Credit (provided annual net earned income of no more than £7,400, as assessed on most recent assessment period)Income SupportIncome-based Jobseeker’s AllowanceIncome-related Employment and Support AllowanceSupport under Part VI of the Immigration and Asylum Act 1999The guarantee element of Pension CreditChild Tax Credit (provided not also entitled to Working Tax Credit and with annual gross income of no more than £16,190)Working Tax Credit run-on – paid for four weeks after one stops qualifying for Working Tax Credit

What is their ethnicity? (Optional)
Mixed / Multiple ethnic groups: White and Black Caribbean, White and Black African, White and Asian, Any other MixedAsian / Asian British: Indian, Pakistani, Bangladeshi, Chinese, Any other Asian backgroundBlack / African / Caribbean / Black British: African, Caribbean, Any other Black / African / Caribbean backgroundOther ethnic group: Arab, Gypsy, Roma or Traveller , Other white minority, Any other ethnic groupPrefer not to say

About the bicycle the person needs
Case* - Tell us a little more about how a bicycle would make a difference to the person's day to day activities, giving as much detail as possible.

Height in centimetres* - Using a bicycle that is too small or too big could prompt uneasiness, pain, and injury, so we need to know accurate height of the person who needs the bike. They can measure this by standing on the floor with shoes off and back up against the wall, and measuring from the base of your feet to the apex point of the head. It might help to have some assistance, if safely possible.

Frame* - Does the person know what type of frame they need? (Note that a step-through is typically the easier to board option for those who might struggle or are less flexible than they once were.)
CrossbarStep-throughNo preference

About Your Organisation
Organisation name*

Reg. charity/ company no.

Organisation website

If you don't have a website or web link with more information, please tell us more about your organisation (including its legal structure as stated in your governing documents)

What theme do you cover, with reference to this person you’re referring? *
Isolation & LonelinessMental Health & WellbeingEmployment SupportEducational SupportESOL/Language SupportProvision of EssentialsAdvice ServicesCommunity CohesionVolunteering

Population Type* - What population type do you cover, with reference to this person you’re referring? (Tick as many as apply)
Older people (65+)Adults (25-64)Young Children (0-4)Children and Youth (5-24)FamiliesCarersLone parentsEconomically disadvantagedEthnic minoritiesEx-offendersFaith groupsHomelessLearning DisabledLGBTQI+People with illnesses/diseasesPhysically disabledRefugees & Asylum seekersThose affected by addictionYouth at risk

Contact for match* - If we find a match for a bike, who is the best person to contact at your organisation? Please provide full name, role title, email and direct phone number.

Submit your referral
Your name*

Your role title at the organisation*

Your contact email*

Let us know how we can stay in touch
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EmailPhone

By submitting, you agree that the information provided is true, correct and complete to the best of your belief and knowledge.

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