AHRMA Benevolent Fund Application Form

Injured riders who have need of monetary aid from AHRMA’s Benevolent Fund are invited to complete the application form, and submit it for consideration. Friends or associates of the rider may also submit the request on his or her behalf. Only full members injured competing at an AHRMA event are eligible to apply for aid through the Benevolent Fund.

Complete the form below fully. You will receive email confirmation of your submission, and a notification will be sent to the members of the AHRMA Benevolent Fund Committee for review. If your application is accepted, you will receive compensation as determined by the committee. If it is rejected you will receive written notification as to why.

Name*
First Last
Member #*
Phone*
Email*
Enter Email Confirm Email
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Venue*
Incident Date*
MM slash DD slash YYYY
Approximate Incident Time

: Hours

Minutes

AM/PM
Incident Description
Injuries sustained
AHRMA Official involved*
First Last
Witnesses*
Health Insurance Company*
Policy Number*
Reason for request*
Consent*
I understand that information in this request, though confidential, may be subject to verification by the AHRMA Benevolent Fund Committee*

AHRMA Benevolent Fund Application Form

Title