Personal Information

Name:____________________________________________________________

Home Address:____________________________________________________________________

City:_________________________________________ State:_____________ Zip Code:_________

Home Telephone Number:______________________ Cell Phone Number:______________________

Email Address:__________________________________ Birthdate:__________________________

Spouse Name:______________________________________________

If you work outside the home:

Place of Employment:_________________________________ Position:________________

Work Address:____________________________________________________________________

City:_________________________________________ State:_____________ Zip Code:_________

Work Telephone Number:____________________ Email Address:___________________________

Motorcycle Information:

Year, Make and Model of Motorcycle:_________________________________________________

Do you have a valid motorcycle license? Yes___ No___ If yes, what year was it issued?____________

Have you completed a Motorcycle Safety Training Course? Yes___ No___ If yes, when?___________

Combined number of miles you rode in the last two years:_____________________

Have you ever been involved in a motorcycle accident? Yes___ No___ If yes, please explain below:

What do you consider to be your strength in motorcycling?

What do you consider to be your weakness in motorcycling?

Emergency Information:

Emergency Contact Name and phone number:

(1)_______________________________________________________________________________

(2)_______________________________________________________________________________

(3)_______________________________________________________________________________

Please list medications you take on a regular basis:

   
Please list allergies you have:

   
Do you wear contacts? Yes___ No___

Please list any other information you feel would be important in the event of an emergency:

Motorcycling is inherently a dangerous sport. While the KKMC places a great deal of importance in riding safely, unexpected emergencies are possible. The KKMC is not responsible or liable for any damage or loss of your motorcycle, nor is the KKMC responsible or liable for any injuries you sustain while riding with KKMC. While KKMC does not require the use of a helmet, we strongly advise and encourage all Kitties to wear one.

Signature:

I certify that the information I have provided is true and correct. I agree to promote the image of women motorcyclists by contributing to a safe and fun environment.

   

_______________________________________________ Signature

_______________________ Date

Please return your completed Information Form and dues to:

Krome Kitty Motorcycle Club
P.O. Box 781361
Wichita, KS 67278