Motorcycle Safety Course Waiver of Release of Liability

Both sides of this form must be completed, signed, and given to your instructor prior to the beginning of 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. (Sign on other side)

NAME:_________________________________________________________________________

ADDRESS:______________________________________________________________________

City, State, Zip:                                                                                                                                                       

PHONE: (_______)__________________________

DATE OF BIRTH: ______________________________

DRIVERS LICENSE NUMBER: __________________________ STATE OF:_______________________

PLEASE ANSWER THE FOLLOWING QUESTIONS:

 #1. DO YOU HAVE ANY SPECIAL NEEDS?

Briefly describe below any medication you are taking, or any hearing, visual, physical, or reading impairment you may have, that might affect your ability to learn in the classroom or to control a motorcycle. This information will not prevent you from taking the course, but will help your instructors to provide you with the best learning experience. If you have no special needs, please write "NONE" below.

__________________________________________________________________________________________

__________________________________________________________________________________________

 #2. EMERGENCY CONTACT?

NAME:________________________________________________________________________________

RELATION:_____________________________________________________________________________

PHONE:_______________________________________________________________________________