Registration Form
To sign up for a
BRC, please
complete this form (enclose one form per
registration) and mail with your check payable to: Alabama Traffic Safety Center,
University of Montevallo, Station 6740, Montevallo, Alabama 35115-6000. A confirmation
letter will be sent to you. If you need additional copies, this form may be
duplicated.
To sign up for an ERC, please
complete this form (enclose one
form per
registration) and mail with your check payable to: Alabama Traffic Safety Center,
University of Montevallo, Station 6740, Montevallo, Alabama 35115-6000. A confirmation
letter will be sent to you. If you need additional copies, this form may be
duplicated.
Name_____________________________________________
Age_______ Birth Date_______________ Circle Sex: M F
Address__________________________________________
City________________
County_____________________
State__________
Zip_____________
Dr. License#___________________State____________
Phone (W)________________ (H)___________________
E-Mail ___________________
Circle Course Choice: BRC ERC
Course Dates: (1st Choice)
Site/Date______________________________________
(2nd Choice)
Site/Date______________________________________
Check below as indicated:
___ If you are taking prescription medication which might adversely
affect your ability to operate a motorcycle, or
have a medical condition which could be aggravated by riding a motorcycle, you must
include a note from your physician stating that you can take this course.
___ Inseam less than 29 inches. (For providing correct size cycle)
Have you ever operated a motorcycle? ______yes ____no
Do you currently own a motorcycle? ______yes ______no
Signature:____________________________ Date:_____________
To the best of my knowledge the above information is correct.
By submitting your signed registration for the BRC/ERC, you are acknowledging an understanding of the stated policy located on the "Registration Information" page of our website and agree to all provisions.