Triangle Bikeworks Interest Form

First Name: Last Name: Email: Phone: City: Address: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix County: Youth's First and Last Name Age Grade 5th 6th 7th 8th 9th 10th 11th 12th School Name Race/ Ethnicity If other, please list your race/ ethnicity Prefered pronouns He / Him / His She / Her / Hers They / Them / Theirs Prefer to self describe If you selected prefer to self describe, use space below Language(s) Spoken at home Why do you want to join or want your child to join Triangle Bikeworks' Programs? Does your child receive free or reduced lunch? How did you hear about Triangle Bikeworks' Programs? Presentation Interest Flyer/ Event Friend/ Word of Mouth Social Media/ Online Other General interest and/ or would like more info for the following programs: (select all that apply)