Build a bike

If you would like to refer someone to the build-a-bike programme please fill out the form below.

Name of referrer

Organisation

Email of referrer

Telephone number of referrer

First name

Last name

Assigned sex at birth

Genderidentity

Ethnic origin

Date of birth

Day

Month

Year

Height

Course type

Time slot preference

Address

Phone

Emergency contact name

Emergency contact relationship to client

Emergency contact number

Do you have an unspent criminal conviction?

Work status

Do you have any health or medical conditions that we need to be aware of?

I authorise the Employment Support Worker from Julian House to store my information securely, and share relevant information with support partners and other organisations as applicable. I understand that I am entitled to access information kept about me.

I can confirm that I am happy for Julian House to use images which were taken of me for marketing purposes.

I can confirm that I am happy for Julian House to use a case study based on my experiences for marketing purposes.