On-Road Course Registration Form – Street Skills LLC Which 2019 course are you registering for? (Choose from list) * Click here and choose... Roanoke - June 28 Roanoke - June 29 (SOLD OUT) Roanoke - June 30 Roanoke -Waiting List (Specify which date in Special Notes area) First Name Last Name Address1 Address2 City State Zip Code Date of Birth (MM/DD/YY) * E-Mail * Cell Phone Home (Alternate) Phone Emergency Contact Name Emergency Contact Phone Relevant Medical Info (bee sting allergies, asthma, etc.) Make and model of motorcycle you’ll be using Total Years of Riding Experience Average Miles Ridden per Year Approximate Lifetime Miles Ridden What is your usual road riding pace? Comfortable Brisk at Times Intense
Do you have a valid motorcycle endorsement on your license? Yes No How often do you have "close calls" when riding on the street? Rarely Sometimes Frequently Your Driving Record is... Squeeky clean A few blemishes The traffic court judge knows me by name You will have appropriate medical insurance at the time of the course? * Yes No You agree to be responsible for damage to your motorcycle or property? * Yes No Have you verified that your motorcycle is properly registered, insured and inspected? * Yes No Have you properly assessed the operating condition of the motorcycle you will be using in this course, specifically lights, tires and brakes? Yes No Are you a current AMA member? No Yes AMA # if member T-Shirt Size S M L XL XXL How did you hear about Street Skills?
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