EAB Registration and Payment Form

Select $20 Fee

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USD

Campaign

Your information

First Name *

Last Name *

We *MUST* be able to contact you by email and/or phone

Email *

Data Privacy & Consent

Yes, I would like to receive text messages from Community Cycles.

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Height *

Weight *

Today's Date *

Create an account to save your information and access our online portal!

Login Name *

Password *

Retype Password

Demographic information

Thank you for sharing this information with us. It helps us find additional funding and grants to grow our Benefit Bike program, getting more people on bikes.

Gender

Birthday

Ethnicity

African American

American Indian/Native American

Asian/Pacific Islander

Decline to Answer

Latino/Hispanic

Other

Unknown

White/Caucasian

Primary Household Language

English

Spanish

Other

Are you homeless?

Yes

No

Income percent of AMI

under 30% AMI

under 50% AMI

under 80% AMI

over 80% AMI

Area Median Income (AMI) for a Household in Boulder County

30% = $30660 to $54330 per year for household of 1 to 7 people 50% = $51100 to $90550 per year for household of 1 to 7 people 80% = $81760 to $144880 per year for household of 1 to 7 people

Payment Details

Card

or enter your card details below

Cardholder First Name *

Cardholder Last Name *

Cardholder Email

Card *

Payment Form Unable to Load: Your payment form is blocked by a firewall. This is most commonly due to use of an anonymous, untrusted IP address. If you are using a VPN to anonymize your IP, we recommend connecting through your local IP to complete your payment.

Billing address is the same as mailing address

Address Line 1 *

Address Line 2

City *

State/Province *

Zip *

Country

Payment Form Unable to Load: Your payment form is blocked by a firewall. This is most commonly due to use of an anonymous, untrusted IP address. If you are using a VPN to anonymize your IP, we recommend connecting through your local IP to complete your payment.