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.

    First Name *

    Last Name *

    Age range *

    Phone number

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

    Address line 2*


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

    Do they rent or own their home?*

    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):

    What is their ethnicity? (Optional)

    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.)

    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? *

    Population Type* - What population type do you cover, with reference to this person you’re referring? (Tick as many as apply)

    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.

    Your name*

    Your role title at the organisation*

    Your contact email*

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