Fillable Form 1: North Carolina Department of Transportation Bicycle (North Carolina Department Of Transportation)

Fill Online, Printable, Fillable, Blank Form 1: North Carolina Department of Transportation Bicycle (North Carolina Department Of Transportation) Form

Use Fill to complete blank online NORTH CAROLINA DEPARTMENT OF TRANSPORTATION (NC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 1: North Carolina Department of Transportation Bicycle (North Carolina Department Of Transportation)

On average this form takes 7 minutes to complete

The Form 1: North Carolina Department of Transportation Bicycle (North Carolina Department Of Transportation) form is 4 pages long and contains:

  • 0 signatures
  • 9 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

U.S.A. forms for North Carolina Department Of Transportation

BROWSE NORTH CAROLINA DEPARTMENT OF TRANSPORTATION (NC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
North Carolina Department of Transportation Division of Bicycle and Pedestrian Transportation, page 1 of 4
North Carolina Department of Transportation
Bicycle Helmet Initiative - 2020 Call for Applications
Submittal Deadline is January 06, 2020
I attest that the information given in this application is true to the best of my knowledge; and I as
a participant of a bicycle safety and awareness program in my community do promise to make every
effort to distribute any awarded helmets to low-income children who would most benefit from this
initiative.
______________________________________ __________________________________
Name Title
______________________________________
Date
North Carolina Crash Facts:
Each year in North Carolina, an average of 20 bicyclists are killed while bicycling, one in six bicyclists
killed in NC are under the age of 16
1
. Children ages 5 to 14 are seen in emergency rooms for bicycle
related injuries more than any other sport. Typically, only 45 percent of children usually wear helmets
2
.
Helmets can reduce the risk of severe brain injuries by 88 percent
3
.
Funding for the Bicycle Helmet Initiative is made possible through the “Share the Road” specialty
license plate. Persons dedicated to bicycle safety in North Carolina have continued to support this
initiative that provides funding that makes the Bicycle Helmet Initiative possible for the children in North
Carolina that will benefit most from this initiative.
(
1
NCDOT, Crash Data Tool -Bicycle Injury Query- 2012,
2
Safe KidsWorldwide-www.safekids.org,
3
Helmet Safety Institute –www.helmet.org)
Applicant Information
Organization applying for the Bicycle Helmet Initiative award:
Contact Person:
Title:
Best Day-Time Phone Number:
Fax Number:
E-mail Address:
Mailing Address (PO Boxes & residential addresses are not acceptable):
City:
State:
Zip Code:
North Carolina Department of Transportation Division of Bicycle and Pedestrian Transportation, page 2 of 4
Application Questionnaire
(All questions are to be filled in completely)
1) The Bicycle Helmet Initiative award is specifically provided to make helmets available to low income
children. Considering this, how many helmets would you be able to distribute?
a. 25 b.50 c. 75 d. 100
2) List the community groups you plan to partner with to distribute the helmets:
(Support letters can accompany application packet; partnership is not mandatory for qualification
but each letter of support will increase the application’s chances of award.)
a. _ _
b. _ _
c. _ _
d. _ _
e. _ _
3) List any bicycle safety programs or events you are aware of in your local area (include school,
police and community programs – Use space to state if no programs exist in your area).
a. _ _
b. _ _
c. _ _
d. _ _
4) Do you plan on utilizing the North Carolina “Let’s Go NC!” Bicycle and Pedestrian Safety
Curriculum (https://connect.ncdot.gov/projects/BikePed/Pages/LetsGoNC.aspx) as part your helmet
distribution efforts?
a. Yes No
5) Describe any helmet or bicycle safety initiatives or events you were involved with in the last year.
Include information on the target audience and how many individuals were reached:
North Carolina Department of Transportation Division of Bicycle and Pedestrian Transportation, page 3 of 4
Narrative Description
(Please limit descriptions to space provided)
6) In the space provided, please describe your bicycle safety program and how helmets will be
distributed to low income children. If you answered ‘yes’ to Question (4), specify how you will
incorporate the Let’s Go NC! curriculum.
7) Provide your explanation for the requested number of helmets in Question (1).
North Carolina Department of Transportation Division of Bicycle and Pedestrian Transportation, page 4 of 4
All groups/organizations that receive helmet awards through the Bicycle Helmet Initiative will be required to forward a brief
summary report of their program. This report can be a page or less, but no more than three pages. For all pictures that
accompany reports a signed parental consent must be kept on record by the host organization for a period of three years.
NCDOT, Division of Bicycle and Pedestrian Transportation reserves the right to use information and images furnished
through this initiative at its own discretion.
I understand that a summary report must be submitted 30 days following the bicycle safety event.
I understand that I/my organization must obtain parental consent for all images.
Notes: 1. Submission of application to the Bicycle Helmet Initiative is not a guarantee of award.
2. PO Boxes and Residential mailing addresses are not acceptable for helmet delivery.
These addresses are screened by our helmet vendor and will be not be processed. Only
manned commercial addresses should be provided to receive helmets. Please verify
the address provided meets this criteria in order to avoid delays.
Submittal Information
E-mail Address:
Bryan Lopez
Subject Line: 2020 Bicycle Helmet Initiative Application
Email: balopez@ncdot.gov
Attachment preference format: PDF
Mailing Address:
Bryan Lopez
NCDOT Division of Bicycle and Pedestrian Transportation
1552 Mail Service Center
Raleigh, NC 27699-1552
Important Web Links:
Program Website.
Program Overview and Guidelines.
NCDHHS Traumatic Brain Injury Program.
The deadline for applications is
5:00PM on Monday January 06, 2020
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 1: North Carolina Department of Transportation Bicycle (North Carolina Department Of Transportation)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document