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