Application for the 2021 OpiCure Foundation Cycling Program
If you have struggled with Opioid Addiction or have been diagnosed with Opioid Use Disorder we want to introduce you to our program! Please complete the form below to apply for an opportunity to ride with us! We will be introducing the bicycle into your recovery treatment program. Application currently open!
Name
First Name
Last Name
E-mail
Phone Number
-
Area Code
Phone Number
Eligibility Criteria: Struggled with Opioid addiction or diagnosed with Opioid Use disorder
Opioid Addiction
Opioid Use Disorder
How long have you been working on your recovery from Opioid Addiction: #months or years?
Age
Height
Weight
Physical Limitations?
Are you on any medication assisted treatment currently for opioid addiction/opioid use disorder?
What is your availability?
Tell us about yourself
Tell us about your first positive memory of the bicycle.
Tell us why you want to be in the OpiCure Cycling Program
What is your experience with riding a bicycle?
What do you hope to accomplish with our structured training and community ride programs?
Submit
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