KNOXVILLE RIDER EDUCATION PROGRAM

Basic RiderCourse (BRC) or Experienced RiderCourse (ERC)

Registration Form

 

Please complete all blanks and sign  (Print legibly)                       Date ____________________________

Name (as on Driver’s License) ____________________________________ Date of Birth ____________

Address _____________________________________________________________________________

City _________________________ State _____ Zip __________ E-mail Address __________________

Telephone (home) _____________________ (work) _____________________ (cell) ________________

Social Security Number ______________ Driver’s License No. _______________ State ____ Type ____

Can you ride a bicycle? _____ Have you ridden a motorcycle before as the “pilot?” __________________

Do you have any disabilities or take medications that may require special arrangements?  Please explain. ______________________________________________________________________________________________

Motorcycle insurance company and policy number (required for Experienced RiderCourse only) ______________________________________________________________________________________________

Sites operate independently and registration forms are not transferable between them.

Circle course requested:  Basic RiderCourse $150.00       Experienced RiderCourse $50.00¹

 (with passenger, add $10.00)

Course Site: _______________________________________________________________________

Class Date:  1^st Choice __________________________  2^nd Choice __________________________

Visa/Mastercard ___________________________________ Expires: _________________________

Signature _________________________________________________________________________

Mail completed registration form and check, money order, or credit card information

to the site you selected, as listed below.  PLEASE DO NOT SEND CASH.

 

Karns High School – make check payable to Knoxville Rider Education Program (KREP)

            Mail to:  KREP, P.O. Box 5582, Knoxville, TN 37928

 

Pellissippi State Technical Community College (PSTCC) – make check payable to PSTCC

            Mail to:  PSTCC, Attn: Rachael Cragle, 10915 Hardin Valley Rd, Knoxville, TN 37933

 

Walters State Community College (WSCC) – make check payable to WSCC

            Mail to:  WSCC, Attn: Allison Belfry, 500 S. Davy Crockett Parkway, Morristown, TN 37813

 

¹Graduates of the Basic RiderCourse need three months and 1,000 miles of experience before enrolling in the Experienced RiderCourse.  All others need two years and 5,000 miles of experience.