Application

Eligibility Criteria

  • Age: 5 – 17
  • Must be first bike (recreational only, not racing)
  • Must have an opthamologist report with phone number for contact. Full report regarding visual aquity (full eligibility requirements are being developed for visually impaired children and RMF reserves the right to prioritize those different degrees of impairment.)
  • Must agree to always wear a helmet when on the bike.
  • Must agree to help fund raise for another child’s tandem.

Rush Miller Foundation reserves the right to change any of these requirements without prior notice. Changes become effective immediately and may not be reflected on the website.

Contact Information



Disability

Tell us a little more about the child’s visual impairments and any other disabilities.



Questionnaire

Do you agree to always wear a helmet?

YesNo

Are you willing to fundraise for another child’s bike?

YesNo



Tandem Questions



Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that any false statements, omissions, or other misrepresentations made by me on this application will disqualify me from receiving assistance from the Rush-Miller Foundation.

Thank you for completing this application form and for your interest in the Rush-Miller Foundation. Please provide this application along with a letter from the child’s eye doctor with diagnosis and visual acuity to Eric@rushmillerfoundation.org.