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Driver Evaluation Registration

Please submit the form below and we'll have an instructor contact you within 48 business hours to set up your evaluation.
Evaluation Reason
Student Information
Emergency Contact Information
Student Medical Information

Does the student wear glasses / contacts?*

Does The Student Have Any Impairment That Would Prevent Him / Her From Receiving And Applying Verbal Instruction / Direction ? If So, Please Explain:*

Are There Any Conditions That We Should Know About That Could Affect A Student's Driving Capability Physically?*

Does The Student Take Any Medication? If So, What Kind & What Is It For? (Please List All)*

Please Let Us Know If The Student Has Ever Been Diagnosed With Any Of The Following: (Check all that apply)

Comments*