This health information must be received before the student
has his/her first driving hour.
I give permission for Student's Name
Social Security
Number
to take Driver Education classes.
I understand that all scheduled driving times must be kept
and that failure to keep a scheduled appointment without 24
hours advance notification will result in a charge of $35.00
per hour. Also, I understand that if my child shows up for a
scheduled appointment and does not have their Learner’s
Permit with them I will also be charged a fee of $35.00 and
my child will not be able to drive. In addition, I
understand that all classes and driving hours must be
completed within one year of registration or 3 months for
Drug and Alcohol Program
Parent's
Signature
Telephone Number
By entering your name in this box, you
are bound by Federal Law Sec. 221wwab Rev.211a as if you had
signed a hard copy of this document.
Print Name in box
Relationship Enter
Date -- mm/dd/yy
Please check below any handicaps or limitations that the
student may have:
If you have checked "Yes" to any of the above, please
explain:
Does the student take any medication regularly?
Yes
No If yes, what is it? Describe below
Do you consider the student capable physically, mentally,
and emotionally to drive a car?
Yes
No
Do you wish a conference with the Driver Education
Instructor?
Yes
No
