Chapter E
Participation Information

In order to receive the Chapter Newsletter, special email for events and social functions, please complete the information listed below. If you do not wish to be included on the Chapter E Roster please let us know.

NAME:_____________________________________________________ BIRTHDAY______/______/XXXX

CO-RIDER:_________________________________________________ BIRTHDAY______/______/XXXX

MEMBERSHIP NUMBER:_______________________________________EXPIRES:______/______/______

ANNIVERSARY (if applicable):________/________/________

MAILING ADDRESS:_____________________________________________________________________

CITY:___________________________STATE:_________ZIP:______________

E=MAIL:______________________________________________________________________________

HOME PHONE:_____________________________ CELL PHONE:________________________________

NUMBER OF YEARS RIDING:__________

EMERGENCY CONTACT NAME:____________________________________________________________

RELATIONSHIP:_______________________ PHONE:___________________________________________

TYPE OF BIKE/YEAR/COLOR:______________________________________________________________

CURRENT RIDER EDUCATION LEVEL (circle) 1 2 3 4 HAVE YOU COMPLETED A (MSF) OR (ERC)

COURSE:____________WHEN:___________ FIRST AID COURSE:_________ CPR CERTIFIED:___________

COMMENTS: (HOBBIES, PLACES YOU WOULD LIKE TO RIDE)

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PLEASE RETURN COMPELTED FORM TO CHAPTER DIRECTOR, ASSISTANT CHAPTER DIRECTOR, OR TO

MEMBER ENHANCEMENT COORDINATOR.