RiderCourse® RiderCoach Preparation Candidate Application



RiderCoach Hiring and Candidate Application Please complete the following information: (type or print) Are you now, or have you ever been an MSF RiderCoach or Instructor? ____ RC # ________ Expiration date: ________PERSONAL Full Name _____________________________________________________________________________________ Address______________________________________________________________________________________________________________________________________________________________________________Employer___________________________________ Occupation _________________________________________ Home Phone (_______) _______ - __________ Cell Phone (_______) _______ - __________ Work Phone (_______) _______ - __________Fax (______) _______ - ________ Email: ________________________________________________________________________________________ Are you 21 years of age or older? ? Yes ? No ? Male ? Female EDUCATION High School or GED ? Yes ? No College/University Graduate ? Yes ? No If Yes, Major_______________________Highest degree earned__________ List other educational institutions you attended or any specialized training you have received. Be sure to identify any certificates or advanced degrees. Use additional paper if necessary.____________________________________________________________________________________________________________________________________________________________________________________________MILITARY If active duty, complete the following: ? Airforce ? Army ? Marines ? Navy ? Coast Guard ? Duty Title______________________________________ Rank _________________________ Organization & Office Symbol ______________________________________How long stationed here? __________________________________ DSN Number_________________________________________Extension _________________________________Commercial Number ___________________________________ Extension ________________________________ MOTORCYCLE EXPERIENCE Do you currently ride a motorcycle on a regular basis? ? Yes ? No - Approximate # of miles ridden per year ________Motorcycle Operator’s License # __________________________________ State ______________________________ How many years have you had a motorcycle license or endorsement? _________________________________________ Have you ever had your license revoked or suspended? ? Yes ? No If yes, When? ____________________________________ Where? __________________________________________Why? ___________________________________________________________________________________________________________________________________________________________________________________How many years have you been a motorcyclist? __________________________________________________________ How many motorcycles do you own? ___________________________________________________________________What type(s) of motorcycle do you own? ________________________________________________________________ What type of riding do you currently do? ? Dirt ?Touring ?Commuting ? Other / specify ________________________ Have you ever been involved in motorcycle racing? ? Yes ? No If yes, what type: ? Dirt Track ? Enduro ? Motocross ? Road ? Observed Trials Are you familiar with the Motorcycle Safety Foundation: Basic RiderCourse (BRC)? ? Yes ? No Motorcycle RiderCourse (MRC:RSS)? ? Yes ? No Experienced RiderCourse (ERC)? ? Yes ? No Advanced RiderCourse/Sportbike Techniques (ARC/ST)? ? Yes ? No Have you attended/completed any of the following motorcycle safety courses? Basic RiderCourse (BRC) ? Yes ? No - If yes, when/where?________________________________________________ Motorcycle RiderCourse (MRC:RSS) ? Yes ? No - If yes, when/where?_______________________________________Experienced RiderCourse (ERC, BRC2) ? Yes ? No - If yes, when/where?_____________________________________ Advanced RiderCourse/Sportbike Techniques (ARC/ST) ? Yes ? No - If yes, when/where?________________________ Other _____________________________________________________________________________________________Describe in detail why you want to become an MSF-certified RiderCourse RiderCoach. Use additional paper if necessary. (This is a screening process. What sets you apart?)____________________________________________________________________________________________________________________________________________________________________________________________________Give a brief description of any other teaching experience.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CHARACTER Have you ever been convicted of (including a plea of guilty or no contest) a felony, or serious misdemeanor, other than a minor traffic violation? ? Yes ? No Are you now undergoing, or have you ever undergone treatment during the last five (5) years for the use of drugs, narcotics or excessive alcohol use? ? Yes ? No Do you have any medical condition that requires accommodation or that would otherwise impair your ability to safely perform the duties of a RiderCoach? ? Yes ? No If yes to any of the above, please explain fully: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SPONSORSHIP Are you being sponsored for this course? ? Yes ? No If yes, by whom? _________________________________________________________________________________What assistance will your sponsor provide? ________________________________________________________________________________________________Where will you teach rider training after graduation? Have you talked to them? ________________________________________________________________________________________________ACKNOWLEDGEMENTS This application does not guarantee a position in a RiderCoach Preparation Course nor does it guarantee that the Motorcycle Safety Foundation (MSF) will issue the applicant a RiderCoach Certification. If the applicant is offered a position in a RiderCoach Preparation Course and the applicant successfully completes the RiderCoach Preparation Course, the MSF may issue a RiderCoach Certification to the applicant. A RiderCoach Certification will only be issued upon execution of a RiderCoach Certification Agreement between the applicant and the MSF. This application shall become an integral part of any RiderCoach Certification Agreement that may be executed between the applicant and the MSF. Unless and until the MSF issues a RiderCoach Certification to the applicant, the applicant is not an authorized, certified RiderCoach and may not make any representations or perform any acts as such. I certify that I have read this RiderCourse RiderCoach Preparation Candidate Application in its entirety, and the information contained herein is true and correct and that I have not omitted any relevant information. I understand and agree that falsification of any information provided herein, or the omission of any relevant information, will result in immediate revocation of my MSF RiderCoach Certification. Signature______________________________________________________________ Date ____________________Requirements to become a North Carolina RiderCoach include:Licensed, experienced motorcycle operator with a minimum of 3 years licensed riding experience. High School diploma or equivalent.21 years of age minimum.Driving record with no more than 3 moving violations, no alcohol related traffic violations, and no driver’s license suspension, revocation, or denial within the three years preceding the date of application to become a coach. Graduate of a Motorcycle Safety Foundation Course (BRC, ERC or BRC2).Have a recommendation from a current RiderCoach.Certified in CPR.You will be expected to be a role model for North Carolina motorcyclists, and as such, will be expected to wear the proper gear, to include a DOT helmet, eye protection, sturdy over the ankle footwear, long pants of durable material, long sleeved shirt or jacket and full fingered gloves; ANYTIME that you ride a motorcycle.Do you meet these above requirements? ? Yes ? No If not, please explain: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Teaching a motorcycle safety course is physically demanding. It requires long hours, walking several miles in the course of a day, bending and stooping to place cones, and sometimes the need to push inoperable motorcycles for distances up to ? mile. Hot and cold weather conditions can add to the strenuous conditions you will encounter while teaching the course. Do you feel you are physically capable of performing this job? ? Yes ? NoTo maintain certification, RiderCoaches are required to teach a minimum of three classes a year in the N.C. Community College System, and attend an annual update training session. You will also be required to follow the MSF RiderCoach Rules of Professional Conduct.You will also need to request, a copy of your driving record. In North Carolina, this can be done through the NC DMV website. Dependent upon the state of residence and situation, it may take several weeks to obtain the record. Don’t delay the submission of your RiderCoach application while you wait for the driving record. You can send the driving record at a later date or bring it to the first night of your class. You will be required to submit a driving record every two years coinciding with your MSF recertification.Do you agree to these conditions? ? Yes ? NoIf you are not currently certified in CPR, you must obtain this certification prior to teaching your first class.I certify that I have read and understand the requirements to become a RiderCoach in North Carolina and that the information contained herein is true and correct and that I have not omitted any relevant information. I understand and agree that falsification of any information provided herein, or the omission of any relevant information, will result in immediate revocation of my North Carolina RiderCoach Certification. Signature______________________________________________________________ Date ____________________2/16 ................
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