Motorcycle Safety Program
 

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.