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.

 

Circle course requested – Basic RiderCourse® $150.                              Experienced RiderCourse® $50.¹

                                                                                                                                 With passenger – add $10.

 

Course site:  _____________________________________________________________________________

 

Class Date:  1st choice_____________________ 2nd 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

 

 

¹ Graduates of the Basic RiderCourse® need 3 months and 1000 miles of experience before
enrolling in the Experienced RiderCourse®.  All others need 2 years and 5000 miles of experience.