LIMITED PARTICIPATION OR ADULT DRIVING LESSON ENROLLMENT SHEET

PLEASE PRINT CLEARLY AND USE YOUR FULL LEGAL NAME

LAST NAME_________________________FIRST_________________________________M.I._________

PERMIT#____________________________ DATE ISSUED __/__/_____

ON CAPE ADRESS_______________________________TOWN__________________________ZIP________________

MAILING ADRESS_______________________________TOWN__________________________ZIP________________

OFF CAPE ADDRESS (IF APPLICABLE)____________________________________TOWN____________ZIP_______

PHONE#_______________________________________________DATE OF BIRTH_____________________________

STUDENT CELL#________________________________________

PARENT NAME &CELL#_____________________________________________________________________________

WORKPLACE_________________________________________________TOWN_______________________________

SCHOOL__________________________________________________________________________________________

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ALL THE

INFORMATION LISTED IN THE PACKET

PARENT SIGNATURE__________________________________________DATE________________________________

STUDENT SIGNATURE_________________________________________DATE________________________________

ENROLLMENT SHEET PROCESSED WITH A NON-REFUNDABLE DOWN PAYMENT AND CLASSROOM LETTER

IF APPLICABLE

DATE PAID______________AMOUNT____________CHECK____________CASH____________MONEY ORDER____

CLASS LETTER RECEIVED_________________________

LAST REVISED 1/29/09