14 Hour Adult Class 12/24/2018
Drive Dat Academy would like to make your experience in our driving school first class. Please fill out the information below so we can prepare the documents with your information in order to save you the time from filling out the forms. Drive Dat Academy would like to thank you for choosing us for your driving education specialist. We will see you Saturday 12/24/2018. Remember Registration begins at 8:00 AM. Please make sure you have this form filled out by 5:00 pm Friday 12/21/2018.
Email address *
First Name *
Your answer
Middle Name *
Your answer
Last Name *
Your answer
Home Adress *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Date of Birth *
MM
/
DD
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YYYY
Age of Student *
Your answer
Sex *
Eye Color *
Height in Feet *
Inches *
Students Weight in Pounds *
Your answer
Hair Color *
Does the student wear glasses or contacts *
Home Phone Number *
Your answer
Work Phone Number
Your answer
Students Cell Phone Number *
Your answer
1. Does the student have any medical conditions that would pose a concern with the student’s behind-the-wheel instruction (epilepsy, asthma, color blindness, hearing loss, etc.)? *
2. Does the student have any mental or physical impairment which could affect his/her ability to drive a motor vehicle safely? *
3. Has the student experienced unconsciousness other than normal sleep? *
4. Is the student’s visual acuity at least 20/40 corrected? *
5. Does the student require any special accommodations to participate in this course (i.e., oral tests, interpreter, seating arrangements, adaptive equipment)? *
Describe locations where you have driving experience. Check the appropriate box(es) *
Required
What type of Identification will you provide the day of class.
How did you hear about us? *
Your answer
A copy of your responses will be emailed to the address you provided.
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