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Teen Beginner Course Enrollment

Please complete the form as completely as possible to start your enrollment in our school.
Class Date and Program Selection

Student Information

Guardian 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)