TENNESSEE DEPARTMENT OF SAFETY

Tennessee Motorcycle Rider Education Program Waiver Form

This form must be completed, signed and returned prior to beginning your on-cycle instruction.

Participants under the age of 18 years must have the signed approval of a parent or legal guardian to enroll in this motorcycle safety course.

NAME: ______________________________________________________________________
                  (first)                                     (middle)                                     (last)

ADDRESS: ____________________________________________________________________

              ____________________________________________________________________

PHONE: (            )                                              DATE OF BIRTH: ____________________________

DRIVER LICENSE NUMBER: _________________________________ STATE OF: ________________
(If Applicable)

RELEASE, WAIVER AND INDEMNIFICATION

The undersigned participant and his/her parent or legal guardian (if under the age of 18 years) does hereby execute this release, waiver and indemnification for him/her self and his/her heirs, successors, representatives and assigns; and hereby agrees and represents as follows:

To release LearnToRide.ORG, the Tennessee Technology Center of Nashville, its members, employees, agents, representatives, The Tennessee Department of Safety, The Motorcycle Safety Foundation and other organizations affiliated with this course from any and all liability, loss, damage, costs, claims and/or causes of action, including but not limited to all bodily injuries and property damage arising out of participation in the motorcycle training course referred to above, if being specifically understood that said program includes the operation and use by the undersigned participant and others of motorcycle. The undersigned further agrees to indemnify LearnToRide.ORG, The Tennesee Technology Center of Nashville, it's employees, members, agents, representatives, the Tennessee Department of Safety, the Motorcycle Safety Foundation and other organizations affiliated with this program and hold them harmless for any liability, loss, damage, cost, claim, judgment or settlement which may be brought or entered against them as a result of the undersigned's participation in said program. This indemnification shall include attorney's fees incurred in defending against any claim or judgment and incurred in negotiating any settlement. It is understood and agreed that the undersigned shall have the opportunity to consent to any such settlement, provided, however, that such consent shall not be unreasonably withheld.

Signature of Participant: ______________________________________ Date: ___________________

Signature of Parent/Guardian: ___________________________________ Relationship: ______________
(Required only if the participant is under the age of 18 years)

SF-0875 (Rev. 1/96)