Use the student’s full name as it appears on his or her birth certificate.    

Last Name:	First Name:			Middle Initial:
Residential Street Address:			Town:
Mailing Address:			Town:
Summer Address (if applicable):			Town:
Home Phone:
Cell Phone:
Work Place:
School:
Learner's Permit #:			Permit Issue Date:
Permit Issue Date:
Social Security #:
Date of Birth:
Enrollment sheet will be processed with a minimum non-refundable payment of $100.00
Selected Course:
Course Date:
Course Location:
Date Paid:
Amount Paid:
Check # or Cash:
Signing the attendance sheet at each classroom session is mandatory for completion of this course.  Any missed signatures will result in a missed class and will require a make-up class to complete the course.   No refunds will be given to the parent or student if the student fails complete the course due to poor attendance or suspension from the program due to a violation of the school rules.  If for any reason the student defaults on his/her scheduled driving lesson without a 24-hour notification, a $40.00 fee will be charged.  The entire driver's education program (classroom hours plus driving hours) must be completed in one year.
Important Notice:   Please read all information on this page prior to signing this official enrollment form.
Parent's Signature:		Student's Signature:

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