Name *

Nickname *

Address *

City/Town *

Province *

Postal Code *

Phone Number *

In your own words, what happend to you *

What do you need the Support for? (please list in point form what this money will be used for and by whom) *

Do you have insurance coverage? (yes or no) *

Do you need someone to haul/PU your bike? (yes or no) *

Do you have storage for your bike? (yes or no) *

Do you have family/friends to assist you once you get home? (yes or no) *

Was this accident reported to police? (yes or no) *

Was the accident your fault? (yes or no) *

Were there alcohol or illegal narcotics involved? (yes or no) *

Was excessive speed or distracted driving involved? (yes or no) *

By submitting this application form, you are verifying that there were NO alcohol or drug related charges and no excessive speed or reckless riding charges issued by police to you in relation to this accident.

By filling out this for you are not obligated to accept assistance. Whether or not you repay any assistance given to you will be determined based on; your interactions with the awards committee and your expressed needs and unique circumstance.

This fund is meant to assist you/your family with out of pocket expenses incurred due to the accident you were invoved in.