Kokomo Schools

Motorcycle Safety Program

Class Registration Form

BRC Course: $50 per Student

ERC Course: $25 per Student

Please enclose completed registration form and tuition fee for each student

(Please Print)

_________________________________________________________________________________________________________________

Last Name                                                                                       First Name                                                           Middle Initial

_________________________________________________________________________________________________________________

Street Address

_________________________________________________________________________________________________________________

City                                                                          County                                                     State                           Zip Code

______________________________         ______________________________         ____________________________________________

               Home Phone                                                        Work Phone                                                             Email Address 

_________________________________                                                                        ____________________________________________

                *Date of Birth                                                                                                                               Physical Limitations

*Note: Students under the age of 18 yrs must have a parent or legal guardian present on the first day of class to sign a waiver.

__________________________                                __________________________                                      __________________________

          First Choice Date                                                          Second Choice Date                                                          Third Choice Date

For information Email:   mcbblinger@yahoo.com   or call 765-450-5300. DO NOT CALL THE SCHOOL OR TRANSPORTATION DEPARTMENT!!! 

Please make checks payable to:   Motorcycle Safety Program

                                        Mail to:          Motorcycle Safety Program

C/O Dan Bolinger

                                                                1408 N. Leeds St.

                                                                Kokomo, IN 46901

**Please register a minimum 5 days prior to the class of your first choice. Your registration fee will not be returned without notification of cancellation 72 hours before the scheduled class.