University of Montevallo - Alabama Traffic Safety Center

Alabama Traffic Safety Center

Motorcycle Safety Program

Registration Form

To sign up for a BRC or the BRC2 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: Male Female
Address_______________________________________________
City______________________________ State_______________________________	County________________
Zip ____________________________
Current Driver's License Yes _______ No ________	State___________
Phone (W)________________	(H)___________________
E-Mail _____________________________________
Circle Course Choice: BRC; BRC2 (For BRC2 ONLY: Name of Passenger_______________________________ Age ___________.)
Course Dates:(1st Choice) Site/Date______________________________________
Course Dates: (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
PLEASE NOTE Classes with less than 5 enrolled students will be canceled. Notification of cancellation will be made by telephone and/or e-mail on Wednesday afternoon by 5:00pm before that Friday or Saturday class date. Signature:__________________________________________
Date: __________________________________________
To the best of my knowledge the above information is correct.

By submitting your signed registration for the BRC or BRC2 Skills Plus you are acknowledging an understanding of the stated policy located on the "Registration Information" page of our website and agree to all provisions.