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• Your e-mail address*:
• Your name*:
• Day time telephone*:
• Evening telephone (optional):
• Name of your school or organization*:   
• Address*:
• City*:
• State*:
• Zip Code*:

What is your affiliation with this school or organization? Drivers Ed Teacher Program Coordinator Public Relations Officer Continuing Ed Coordinator Senior Center Advisor Other ~ Please Select ~

When would you like to schedule the Motorcycle Awareness Program?
January February March April May June July August September October November December ~ Select Month ~ Monday Tuesday Wednesday Thursday Friday Saturday Sunday ~ Select Day ~ Morning Afternoon Evening ~ Select Time ~

How many people will attend the Motorcycle Awareness Program? 10 - 15 people 15 - 30 people 30 - 50 people over 50 ~ Please Select ~

What is the age group of the people attending? Teenagers Young Adults Middle Aged Senior Citizens Mixed Age Group ~ Please Select ~

Do you have a TV and VCR / DVD player available for use? Yes No ~ Please Select ~

Do you have a chalk / white board available for use? Yes No ~ Please Select ~

Have we presented a Motorcycle Awareness Program at your school or organization before? Yes No ~ Please Select ~

Additional infomation, comments or questions: