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Student-Driver Referral From
Please use this form to refer a student-driver to 4-POINT DRIVING SCHOOL. In light of the current health pandemic, we only accept student-drivers who have been fully vaccinated and received the booster shot. Thank you for understanding.
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* Indicates required question
Name of Referring Agency/Individual:
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Your answer
Full Address of Referring Agency or Individual: Number, Street, City, State, and Zip Code:
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Your answer
Referring Agency Point of Contact Name:
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Your answer
Referring Agency Point of Contact Phone Number:
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Your answer
Referring Agency Point of Contact E-mail Address:
Your answer
Full Name of the Student-Driver Being Referred:
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Your answer
Student's date of birth:
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MM
/
DD
/
YYYY
Full Address of the Student-Driver Being Referred:
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Your answer
Name of parent or guardian:
Your answer
Phone Number of the parent/guardian or the Student-Driver Being Referred:
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Your answer
Email Address of the Student-Driver Being Referred:
Your answer
Has the student-driver being referred been vaccinated for COVID-19?
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YES
NO
Not Sure
Services Desired for the above student:
Behind-the-Wheel Driving Instruction and Coaching
Rehabilitative Driver Evaluation
NY State Five-Hour Prelicesing Prep Course/Seminar
Insurance/Point Reduction Course
Gift Certificates
Special Educational Accommodations: please indicate if the student-driver has any of the following at there home school:
IEP Plan
504 Plan
Other Physical Accommodations
Language Accommodations
Student-Driver Assignment Statement: completing this form constitutes assigning the above mentioned student-driver to 4-Point Driving School for driver and traffic safety instruction. The referring agency or individual above shall be billed accordingly and based upon the appropriate plan for the enlisted student. Below, please type the referring agency's name of the point-of-contact in the below field to indicate agreement to this assignment as well as any associated invoicing: (enter your name below)
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Your answer
Additional pertinent info, questions, and/or comments:
Your answer
How did you hear about us? Where
DMVs office
Google Ad
Facebook Ad
Newspaper Ad
Radio Ad
Online Search
A Friend or ra Rlative
An Online Group
Saw student driver car on the road
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