Cell Phone Number Address Drivers' License Number * State/Province of Driver's License * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Do you have a Motorcycle Endorsement? * Branch of Military *
Which branch of the military are you in?
Please input your current rank
Present Military Status *
What is your present military status? Active, Reservist, National Guard, other
Commanding Officer's Name *
Sgt. Cpt. Maj. 1LT 2LT LTC Col. BG MG LTG Gen. RDML RADM VADM Other
Commanding Officer's Phone Number Emergency Contact Name
Relationship * Emergency Contact Best Phone Number Why do YOU want this scholarship? *
Share your rationale for applying for this scholarship. Please include any riding experience you have that is relevant. Offer us reasons why you would be a confident, positive role model and spokesperson for the Women's Motorcyclist Foundation's Dirty for Good training and charitable goals.
Please read carefully and confirm with your initials that you agree with all of the statements where 0 to 4 characters are required to be entered. Enter the information as requested for the remaining fields where detailed information is requested.
Fitness to Ride *
I meet the physical and mental requirements to participate and will come to training rested and ready to learn. I will bring my license with its motorcycle endorsement to the DIRTY FOR GOOD Off-Road Riding Camp.
License Endorsement for Riding a Motorcycle *
I either already have or agree to secure my motorcycle endorsement through an approved motorcycle training school prior to attending Dirty for Good. I will call or write Sue Slate should I need assistance. firstname.lastname@example.org / 585-415-8230
Camping Consent *
I understand that this is a camping venue and I will be allocated a tent to use. However, I agree to bring my own sleeping bag and other camping essentials (i.e. a flashlight).
Scholarship Value *
I understand the value of the Dirty for Good Women's Dual Sport Training/Riding Camp Military Scholarship, including the training, riding gear, use of a motorcycle, meals and all other amenities is approximately $2000. I understand the scholarship DOES NOT INCLUDE MY TRANSPORTATION TO/FROM the event location.
Agreeing to Fundraising Mission *
I understand that Dirty for Good is a Mission-Based Fundraising Event that provides Dual Sport
Riding/Training with each rider committing to raise a minimum of $300. I understand I will be given
the ability to raise my minimum through an electronic fundraising page which I can personalize.
(1) 50% goes to Final Salute, Inc. https://www.finalsaluteinc.org to support homeless/struggling female
veterans. (2) 25% goes to the Women's Coalition of Motorcyclists Off-Road Riding Train-the-Female-
Trainer Scholarship fund. (3) 25% goes to Women's Motorcyclist Foundation's Youth Scholarship offroad
riding training fund for youths 17 & younger.
Agreeing to Terms for THANK YOU FOR YOUR SERVICE Ride-In *
I understand there will be a "THANK YOU FOR YOUR SERVICE RIDE-IN" in September 2019. (Sunday
Date to be determined). Unless I am deployed, I will make every effort to attend & participate in this check
presentation event. I understand that my lodging and meals will be covered. I understand that I will ride
the bike that I used during the Dirty for Good Dual Sport Camp. Again, transportation is not covered.
Medical Certification *
Provide a list of any PRESCRIPTION medications you take or any acute or chronic medical conditions that you have. This information will be given to medical personnel in the event of a medical emergency. Enter "NONE" if this does not apply to you.
Agreeing to Personal Risk *
I understand that both road and off-road riding involves inherent risk. I accept the risks involved and hold
harmless the Women’s Motorcyclist Foundation, Inc., SheAdV, XPLOR Off-Road Vehicle Training, the
American Motorcyclist Foundation, Inc., Rocky Gap State Park & all other co-insureds.
Statement regarding Personal Safety *
I understand that my individual safety, as well as the safety of every participant, is of the utmost importance.
I agree that the instructors will make the determination as to what riding routes best fit my skills set and will
abide by their decisions and rules. Further, I agree that the organizers, instructors and staff cannot and will not
guarantee my safety. I accept responsibility for my own safety.
Zero Tolerance *
I agree to not mix any substances that would interfere with my judgment, vision, physical or mental condition including but not limited to alcohol, over-the-counter or prescription drugs with the riding experience.
Communication is Key *
I agree to bring any of my concerns, especially concerns revolving around safety, immediately to the event
organizers Gin Shear & Sue Slate.
Modeling Release *
I understand and agree to the use of my image in videos or still pictures for the purpose of promoting the
Dirty for Good program, highlighting women in motorcycling and/or supporting the three fundraising
Consent * Participant Electronic Signature - Enter Your Full Name Below *
DURING CHECK-IN AND ORIENTATION YOU WILL BE ASKED TO REVIEW YOUR RESPONSES ON THIS APPLICATION AND SIGN A REGISTRATION DOCUMENT ALONG WITH READING AND SIGNING OTHER WAIVERS OF INDEMNIFICATION.
This field is for validation purposes and should be left unchanged.