Pioneer Valley Rider Training, Inc. PO Box 991
East Longmeadow, MA 01028
COURSE REGISTRATON FORM
1.Tell Us About Yourself
Day Phone: (____)____________________ Email:_________________________________
Age: Under 18 ☐ Over 18 ☐
Driver’s License #:__________________________________
State:_____________ Zip:_____________________ Evening Phone: (_____)_____________________________ Gender: Male ☐ Female ☐
Date of Birth:________________________________________
2. Which course are you registering for? Basic Riding Course ☐ Experienced Rider Course ☐
3. Pick a Class Code and Group Please identify two CLASS CODES (i.e. PV01, PV02*) & your preferred schedule. CLASS CODES: 1st choice:____________ Select a schedule: Group A ☐ Group B ☐
2nd choice:____________ Select a schedule: Group A ☐ Group B ☐
Please see our brochure or website (www.pvriders.com/schedule) for class schedule and codes PLEASE NOTE: Your registration is not confirmed until you receive a confirmation letter by mail, which will include detailed directions to the training site and list the items you need to bring with you on your training days. YOU ARE NOT CONFIRMED IN ANY CLASS UNTIL YOU RECEIVE THIS CONFIRMATION LETTER!
4. Determine Your Tuition
Basic Rider Course: $315.00
Experienced Rider Course: $175.00 Tuition Enclosed: $_______________
Please make check payable to: Pioneer Valley Rider Training, Inc.
5. Please answer all of the following questions.
Do you have an inseam less than 26 inches?
Are you less than 62” tall?
Do you have a hearing, reading, or other type of disability? If your primary language something other than English?
(if your primary language is English, check “no”)
Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐
If you answered YES to any of the above questions, please call the office prior to registering to discuss if we can accommodate you needs.
Are you a member of Barnes Air National Guard Base? Yes ☐ No ☐
If you are a member of Barnes ANGB, please provide the following information:
Supervisor Name:_____________________________ Have you ever ridden a bicycle?
Yes ☐ No ☐ Your signature below confirms that you agree to the following statement:
“I have read, understand and accept the Course Descriptions, Policies and Conditions as stated on the www.PVRiders.com webpage and in this document.”
___________________________________________________________ __________________________________ Student Signature (required or registration is invalid) Date
Mail this page to the address at the top of the page. Please include a copy of your motorcycle learner’s permit, if you have it.
We must receive you learner’s permit at least two weeks before class begins.
Have you ever driven a motorcycle?
Phone Ext:___________________________ Yes ☐ No ☐