LearnToRide.ORG
Registration Form

  1. Name _____________________________________ Email _____________________________


  2. Address _____________________________________________________________________


  3. City ____________________________________ State___________ Zip Code________________


  4. Day Phone # ____________________ Evening # ____________________


  5. Social Security # ___________________ Driver's License #____________________ St. Issued_______


  6. Do you own a motorcycle?     Yes____ No____ What Make____________________ Engine Size__________


  7. Birthdate: _______/_________/_________ Age_________ Sex________ T-Shirt Size________


  8. Have you taken a rider education course before?     Yes____ No____


  9. If Yes, what kind?     BRC____ ERC____

    Please designate by course number & dates the course that you are registering for. You must attend on dates assigned to each course #.

    1st Choice:         Cs. #
    ____________________         Dates ____________________

    2nd Choice:        Cs. # ____________________         Dates ____________________


  10. How did you learn of this program? _________________________________________________


  11. What made you decide to sign up? _________________________________________________


  12. Can you ride a bicycle?     Yes____ No____ (Course requires that you know how!)


  13. Please provide information on vehicle that you will be driving on campus. Please park in the rear.

    Make/Model
    ___________________________         License #_____________________________


  14. Emergency Contact: _______________________________    Phone #_______________________