Backfill List
The Backfill List is for students who did not pass or did not attend the Basic RiderCourse. If you wish to retake the course from the beginning, please complete this form. Submission to the Backfill List does not guarantee a free spot. To guarantee a seat, you must re‑register and pay for the course.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which location do you live closest to:
*
Please Select
Anderson
Bargersville/Greenwood
Bloomington
Dyer
Fort Wayne
Indianapolis
Lafayette
Plainfield
Richmond
Sellersburg
Which locations are you willing to take a class, for first available (Select all that apply)
Anderson
Bargersville
Bloomington
Fort Wayne
Indianapolis
Lafayette
Plainfield
Richmond
Dyer
Sellersburg
Reason for request
*
Please Select
Counseled Out
Late To Class
Improper Riding Gear
Failed Test
Within 7 Days of My Class
Wait List
Best way to contact you
*
Please Select
Call
Text
Email
Class time preference?
Please Select
AM
PM
First Avaliable
By checking, yes, I understand there is no guarantee I will be placed into a new class without paying a fee or registering for a new class.
*
Yes
Submit
Should be Empty: