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Before submitting your registration for the BRC/ERC Course, please
take the time to review this checklist.
☐
1. I have a valid email address to obtain Logging Coupon Code to take the mandatory eCourse.
☐
2. I have completed the BRC/ERC Motorcycle Rider Registration Form (page1).
☐
3. I have completed the CONREP/GWCC State of Connecticut Rider Education Program Form (page 2).
☐
4. I signed and Initial the CT RIDER ED Waiver/Liability Release Form /Adult or Minor (page 3).
☐
5. I have selected 3 possible classes, a primary class and 2 alternates in case my rst preference is full.
☐
6. I understand registration is on a rst-come, rst-served basis. I will automatically be enrolled in the rst
available course.
☐
7. I have enclosed full payment for the class.
☐
8. I am aware that ALL sessions must be attended in their entire. I understand that if I'm LATE or MISS a
class there is ABSOLUTELY NO REFUND.
Connect With Us: GatewayCT.edu/GREAT-Center - Phone: (203) 285-2300
Email: GW-MotorycleHelp@GatewayCT.edu
20 Church Street, New Haven, CT 06510
MOTORCYCLE RIDER (BRC/ERC) SPRING 2021
MOTORCYCLE RIDER PROGRAM | SPRING 2021
20 Church Street
New Haven, CT 06510
Phone: 203.285.2300
Fax: 203.285.2018
GatewayCT.edu/registrar
INSTRUCTIONS: PLEASE PRINT CLEARLY, AND PROVIDE YOUR SIGNATURE AT THE BOTTOM
SOC. SEC.:_______________________________ StudEnt Id: @ __________________________ D.O.B.: ______/_______/______
Name:
_________________________________________________________ Gender: ☐ Female ☐Male
(LAST) (FIRST) (M.I.)
Address: ______________________________________________________ City ________________________ Zip Code ____________
Phone Numbers: (Home) ____________________________(Cell)_____________________________(Work)_________________________
Valid Email Address: _______________________________________________________________________________________________
Note: BRC students, will send you the log-in Coupon Code you will need for the eCourse.
ValId drIVEr'S lICEnSE: Yes ☐ No ☐
SElECt M
OtOrCyClE COurSe: ☐(BRC) $220.00 ☐(ERC) $100.00
EthnICIty:☐ HispaNic/LatiNo ☐ WHite ☐ BLack or africaN americaN ☐ asiaN
☐ americaN iNdiaN or aLaskaN Native ☐ Native HaWaiiaN or otHer pacific isLaNder ☐ otHer
REGISTRATION
MOTORCYCLE RIDER (BRC/ERC)
SPRING 2021
Type of paymenT: please make CheCk or money order payable To: GaTeway CommuniTy ColleGe
☐ ChECk ☐ MOnEy OrdEr ☐ CaSh ☐ MaStEr Card ☐ VISa ☐ aMErICan ExprESS ☐ dISCOVEr
Card nuMbEr ________________________________________________________________ ExpIratIOn datE ______/_______/______
naME aS It appEarS On thE Card __________________________________________________________________________________________
bannEr Id: @ ________________________
rESChEdulIng FEE: $40.00
FEE paId by: __________________________
please enroll me in on of These Courses:
Enrollment is on a rst come, rst served basis. Providing 3 possible choices will help ensure entry into a class. Please be sure you can attend
on the dates you select! To reschedule a class there will be a fee of $40.00.
REFUND POLICY: If you ocially drop on the last business day before the rst class meeting or prior – 100% refund. Requests must be
made by Friday for courses starting on Monday. If you ocially withdraw on the day of the rst class meeting or later – NO REFUND.
ChOICE CRN Course Title Time Day & Dates Cost
1
2
3
tOtal COSt:
studeNt'S DIGITAL SIGNATURE
datE
GatewayCT.edu/Great-Center | SPRING 2021 Page 1
mm dd yyyy
20 Church Street
New Haven, CT 06510
Phone: 203.285.2300
Fax: 203.285.2018
GatewayCT.edu/registrar
INSTRUCTIONS: PLEASE PRINT CLEARLY, AND PROVIDE YOUR SIGNATURE AT THE BOTTOM
TO REGISTER: YOUR RIDER COURSE REGISTRATION MUST INCLUDE ALL THREE (3) OF THESE COMPLETED FORMS:
1.☐ 2021 - state of ct/gWcc rider ed reg form - (Name, contact info, driver's license #, etc.)
2.☐ 2021
- Brc/erc registratioN form - (Name, SS#, class enrollment choices, payment information.)
3.☐ ct rider ed Waiver/LiaBiLitY reLease - (Adult or Minor Form: Initials and signature required.)
payMEnt MuSt bE MadE WhEn yOu rEgIStEr.
plEaSE nOtE: NotificatioN of eNroLLmeNt WiLL Be Your receipt paYmeNt.
We WiLL Only coNtact You if Your cLass is unaVaIlablE
== rEFund pOlICy ==
If you ocially drop on the last business day before the rst class meeting or prior – 100% refund. Requests must be made by Friday for
courses starting on Monday. If you ocially withdraw on the day of the rst class meeting or later - NO REFUND.
WE CANNOT RESCHEDULE YOU IF YOU MISS A SESSION. THERE ARE NO REFUNDS UNLESS A COURSE IS CANCELED.
CONREP/GWCC
2021 RIDER EDUCATION REGISTRATION
OFFICE USE ONLY
Course #: ___________ Course Dates: ______/_______/______ to ______/_______/______ BRC #: _____ ERC #: _____
Banner ID: @ ______________________________
Rescheduling fee: $40.00
Fee paid by: ______________________________
GatewayCT.edu/Great-Center | SPRING 2021
Page 2
Name: _________________________________________________________ D.O.B.: ______/_______/______ Gender: ☐ Female ☐Male
(LAST) (FIRST) (M.I.)
Address: ______________________________________________________ City ________________________ Zip Code ____________
Phone Numbers* Hm: _____________________________ Cell: _____________________________ Work: ___________________________
*If possible, please provide at least 2 contact #'s. We may need to reach you about your class choices
Valid Email Address: ______________________________________________________________________________________________
Note: BRC students, will send you the log-in Coupon Code you will need for the eCourse.
Valid Driver's License #: ___________________________________
State: __________ Exp. Date:______/_______/______
*Motorcycle Permit #: ___________________________________
State: __________ Exp. Date:______/_______/______
*(A learner's permit is not required for the Basic Rider Course, but you
must have a valid Driver's License.)
Student Digital Signature Date
If REGISTERING for the EXPERIENCED RIDER COURSE, PLEASE ll out this section:
Is license endorsed for motorcycle? ☐
No ☐Yes If yes; Endorsement Date: ______/_______/______
Insurance Company (Not agent): ___________________________________Policy #: ___________________________________
Riding Experience: ______Years Approx. Miles per Year: ______________
I certify that the statements made by me on this registration form are complete and true to the best of my knowledge and belief,
and are made in good faith.
CONNECTICUT RIDER EDUCATION PROGRAM WAIVER AND RELEASE OF LIABILITY – ADULT
1. Mandatory eCourse Completion Certicate
As BRC student I’m required to provide a valid email address to obtain a Log-in Coupon Code. I understand that if I do not complete the
eCourse, I will not be able to get my license. I may retake the course whenever I want to refresher or re-take. (eCourse Re-take is FREE) by
log-in and checking the "Start new attempt" checkbox. (Participant, please initial ________)
(For minor, parent/legal guardian, also initial _________)
2. Acknowledgment of potentially dangerous activity
I understand and am aware that participation in the motorcycle rider education course sponsored by the State of Connecticut is a potentially
hazardous activity. I also understand that this participation involves a risk of injury and even death and that I am voluntarily participating in
these activities and using equipment and/or machinery with knowledge of the dangers involved. Examples of the inherent risks involved
are: I may forget how to brake or otherwise slow or stop the bike when I need to; I may accelerate without intending to; the bike may fall
on me or otherwise strike me; another participant or his/her bike may hit me; I may panic and not do what I was instructed to do. These
risks and dangers may result due to no one’s negligence or be caused by my own actions or the actions of other participants. It is further
acknowledged that there may be risks and dangers not known to us or that are not reasonably foreseeable at this time.
(Participant, please initial ________)
3. Personal Responsibility
I am voluntarily participating in the motorcycle rider education course. I agree to use due care and common sense when participating in this
course and performing these activities, including not participating while under any impairment which would interfere with my physical or
mental abilities. I agree to let the instructor/person in charge know if I see or feel that something is dangerous or that I am not able to safely
do something. While an instructor may encourage me to attempt an activity, I understand that I am best able to judge whether I can do it
safely. I should refuse to do an activity if I feel I cannot do it safely, even if it means that I cannot complete the course and will not receive
reimbursement of the registration fee. The program strongly suggests that I obtain my own private insurance to cover any injuries I may
sustain. (Participant, please initial ________)
4. Release of Liability
In addition to the risks and dangers of injury inherent to this activity, there is also a risk and danger that may because by the negligence of
others, including that of the releases. I waive any and all liability for and cause of action for personal injury, property damage or wrongful
death arising from my participation in this activity, including for claims of negligence, including the negligence, if any, of releases. "Releases"
include the State of Connecticut, the Department of Transportation, the Motorcycle Safety Foundation, the host college, the course instructor,
and all of these entities’ ocers, agents, employees, representatives, executors or their successors. I hereby release and agree that I will not
sue the releases for any and all damage or injury to me or to my property. (Participant, please initial ________)
5. FERPA Consent for Disclosure of Education Records
In order to maintain accurate student records, and for other legitimate business purposes, I hereby authorize Gateway Community College to
release the CONREP/GWCC rider education registration and waiver and release of liability forms to the Department of Motor Vehicle in order
for your license conrmation to occur. (Participant, please initial________)
6. Release of Liability.
I understand and assume the risks arising from participation in the motorcycle rider education course and understand that included within
the scope of this waiver and release is any cause of action arising from the performance, or failure to perform maintenance, inspection,
supervision or control of said areas/activities and for the failure to warn of dangerous conditions existing at said facilities, for negligent
selection or hiring of anyone connected with the activity, or negligent supervision or instruction by releases.
(Participant, please initial ________)
7. Refund/Rescheduling Policy
I understand that the Motorcycle Rider Education course fee is non-refundable. Rescheduling may be allow, onetime only, at the discretion
of the Continuing Education Oce, and requires two weeks’ notice prior to the start of the originally schedule class. A $40 fee will be charge.
(Participant, please initial ________)
Notice to Participants
Although a fee is charged for this course, it is being oered at low cost and no prot for purposes of promoting safety and enjoyment of
riding. This course is fullling a community need by oering a program not easily or otherwise available in the private sector or only available
at higher cost in the private sector.
I acknowledge that I am 18 years of age or older and that I have read and understand the above paragraphs.
Student Signature Date
Adult Page 3
GatewayCT.edu/Great-Center | SPRING 2021
CONNECTICUT RIDER EDUCATION PROGRAM WAIVER AND RELEASE OF LIABILITY – MINOR
1. Mandatory eCourse Completion Certicate
As BRC student I’m required to provide a valid email address to obtain a Log-in Coupon Code. I understand that if I do not complete the
eCourse, I will not be able to get my license. I may retake the course whenever I want to refresher or re-take. (eCourse Re-take is FREE) by
log-in and checking the "Start new attempt" checkbox. (Participant, please initial ________)
(For minor, parent/legal guardian, also initial _________)
2. Acknowledgment of potentially dangerous activity
I [and my parent/guardian] understand and am aware that participation in the motorcycle rider education course sponsored by the State
of Connecticut is a potentially hazardous activity. I also understand that this participation involves a risk of injury and even death and that I
am voluntarily participating in these activities and using equipment and/or machinery with knowledge of the dangers involved. Examples
of the inherent risks involved are: I may forget how to brake or otherwise slow or stop the bike when I need to; I may accelerate without
intending to; the bike may fall on me or otherwise strike me; another participant or his/her bike may hit me; I may panic and not do what I
was instructed to do. These risks and dangers may result due to no one’s negligence or be caused by my own actions or the actions of other
participants. It is further acknowledged that there may be risks and dangers not known to us or that are not reasonably foreseeable at this
time. (Participant, please initial ___________) (For minor, parent/legal guardian, also initial _________)
3. Personal Responsibility
I am voluntarily participating in the motorcycle rider education course. I agree to use due care and common sense when participating in this
course and performing these activities. I agree to let the instructor/person in charge know if I see or feel that something is dangerous or that
I am not able to safely do something. While an instructor may encourage me to attempt an activity, I understand that I am best able to judge
whether I can do it safely. I should refuse to do an activity if I feel I cannot do it safely, even if it means that I cannot complete the course and
will not receive reimbursement of the registration fee. The program strongly suggests that I obtain my own private insurance to cover any
injuries I may sustain. (Participant, please initial ___________) As the parent/legal guardian, I acknowledge that my minor understands this.
(For minor, parent/legal guardian, also initial ___________)
4. Release of Liability
I waive any and all liability for and cause of action for personal injury, property damage or wrongful death arising from my [or my minor’s]
participation in this activity. I hereby release and agree that I will not to sue the releases for any and all damage or injury to me [my minor] or
to my property. "Releases" include the State of Connecticut, the Department of Transportation, the Motorcycle Safety Foundation, the host
college, the course instructor, and all of these entities’ ocers, agents, employees, representatives, executors or their successors.
(Participant, please initial ___________) (For minor, parent/legal guardian, also initial _________)
5. FERPA Consent for Disclosure of Education Records
In order to maintain accurate student records, and for other legitimate business purposes, I hereby authorize Gateway Community College to
release the CONREP/GWCC rider education registration and waiver and release of liability forms to the Department of Motor Vehicle in order
for your license conrmation to occur.
(Participant, please initial ___________) (For minor, parent/legal guardian, also initial _________)
6. Release of Liability
I understand and assume the risks arising from participation in the motorcycle rider education course and understand that included within
the scope of this waiver and release is any cause of action arising from the performance, or failure to perform maintenance, inspection,
supervision or control of said areas/activities and for the failure to warn of dangerous conditions existing at said facilities, for negligent
selection or hiring of anyone connected with the activity, or negligent supervision or instruction by releases.
(Participant, please initial ___________) (For minor, parent/legal guardian, also initial _________)
7. Refund/Rescheduling Policy
I understand that the Motorcycle Rider Education course fee is non-refundable. Rescheduling may be allow, onetime only, at the discretion
of the Continuing Education Oce, and requires two weeks’ notice prior to the start of the originally schedule class. A $40 fee will be charge.
(Participant, please initial ___________)
Notice to Participants - Although a fee is charged for this course, it is being oered at low cost and no prot for purposes of promoting safety
and enjoyment of riding. This course is fullling a community need by oering a program not easily or otherwise available in the private
sector or only available at higher cost in the private sector.
For Minors, the minor and the parent or legal guardian must sign
Parent/Legal Guardian - Digital Signature Print Name Date
Participant’s Digital Signature Print Name Print Name
Minor Page 3
GatewayCT.edu/Great-Center | SPRING 2021
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