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*
