Application / Free Driver Education Eligibility

Name *

Date of Birth *

Last 4 Digits of Social Security Number *

Address/City and Zip Code *

Students Cell Phone Number *

Parents Cell Phone Number *

Emergency Contact Name and Cell Phone Number *

Parents Email Address *

By signing this you understand that your teen is required to complete 24 hrs of classroom. If student misses a day its $20 to make up each day missed. Make up days will be at the end of class. $75 fee to replace DE-964 if lost *

Male or Female *

15- 17 teen .......18 and up Adult *

teen
adult

Signature of Parent/Guardian (Younger than 18)* *

Start Date of Classroom Only Classes *

All Cancellation/supply fees will apply $150. Please Sign that you are aware of this policy. *