Bikes for Kids Louisiana

1. Email *

Your Information

2. Your First Name *

3. Your Last Name *

4. Your Street Address *

5. Your City *

6. Your Cell Phone Number (for calling and text messaging) *

7. Your Relationship to the Child

8. Please add me to the Parker Layrisson Law Firm VIP List so I can receive the monthly Ponchatoula Post community newsletter and free gifts
Yes!No

9. How did you hear about Bikes for Kids?

Nominated Child's Information

You may nominate any kid between the ages of 5 and 15 who resides within 40 miles of our office in Ponchatoula, Louisiana.

10. Child's First Name *

11. Child's Last Name *

12. Child's Age * (Must be between 5 and 15)

13. Child's Height *

3ft5 - 4ft04ft0 - 4ft54ft5 - 5ft05ft0+Not sure

14. Child's Street Address

15. Child's City * (Must reside within 40 miles of Ponchatoula, Louisiana)

16. Parent or Legal Guardian's First and Last Name *

17. Parent or Legal Guardian's Cell Phone Number (for calling and texting) *

18. Parent or Legal Guardian's Email

19. Tell us in 150 words or less what the child did to deserve a new bike *

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1. First Name *

2. Last Name *

3. Email *

4. Phone Number (for calling and texting) *

5. Name (or company name) you would like for us to say the bike was donated by *

6. Would you like to participate in the giveaway of your donated bike and be in the picture to be used on Social Media, Website, Layrisson Law Firm Newsletter, and Promotion of future "Bikes for Kids" programs sponsored by Parker Layrisson Law Firm? *
Yes!No

7. Please make your $250 check payable to Bikes for Kids Louisiana and either drop it off at our Ponchatoula office (located at 200 E Hickory St.) or mail your check to P.O. Box 1860, Ponchatoula, LA 70454. *
I will drop off the check!I will mail the check!

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