Teen Behind-the-Wheel Course Student Registration Form
Please complete and submit this student registration form to begin the enrollment process.
Email address *
Request Course Start Date *
MM
/
DD
/
YYYY
Student First Name *
Your answer
Student Middle Name *
Your answer
Student Last Name *
Your answer
Sex *
Date of Birth *
MM
/
DD
/
YYYY
Home Address (street, city & zip code) *
Your answer
Pick Up Address (if different from home address)
Your answer
Student Cell Phone *
Your answer
Student Current School
Your answer
Select the Documents You Have *
Required
Times Available for Driving Appointments *
Yes
No
More Info Below
Morning (9am - 12pm)
Early Afternoon (12pm - 3pm)
Afternoon (3pm - 6pm)
Evening (6pm - 8pm) *when available
Provide any other availability information we need to schedule driving appointments, especially if you selected "More Info Below" (work, sports, extra-curricular activities, etc.)
Your answer
Driving Experiences You Have Had On the Road *
Required
Have you experienced a physical, mental or visual injury, illness or condition that may affect your ability to safely operate a motor vehicle? *
Have you experienced a blackout, seizure, loss of consciousness or fainting while driving? *
Do you have any reading or learning disabilities that the instructor should know about to help you succeed in becoming a safe driver? *
Do you take any medication or drug that would impair your ability to operate a motor vehicle? *
Parent or Guardian Name & Relationship to Student *
Your answer
Parent or Guardian Cell Phone *
Your answer
Parent or Guardian Email *
Your answer
How Did You Find Out About Our School? *
Required
A copy of your responses will be emailed to the address you provided.
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