Motorcycle Safety Registration Form – Glen Oaks Community College

Name: *

First Middle (Full) Last

Address: *

Street Address City State ZIP Code

Age: *

Email: *

Phone: *

Driver License #: *

Birth Date: *

A copy of your Driver License is required to register for a Motorcycle Safety Course. Please attach below: *

If you do not have a scanner, you may need to use one available through the Glen Oaks library, your public library, or through a retail establishment that offers a document scanning service.

If the course you desire to sign up for has no spots left, you will need to select another course date/time or continue to check back to see if anyone from the filled course has dropped.

Will you be paying your registration fee yourself? *

Yes
No

If not, please list the name of the individual who will be paying your registration fee:

Do you intend to pay the registration fee for another applicant?

Yes
No

Name of the additional applicant(s) whose registration fee you will be paying (besides yourself):