Driving Application
LifeSkills Driving School LLC
Phone Number: 417.343.1064
                            417.755.7620
Rod@lifeskillsdriving.com
lifeskillsdriving4u@gmail.com
Rod Mathewson-owner/instructor
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Email *
Students Name *
Students Phone Number *
Street Address, City  *
Students Birthdate *
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Parent/Guardian Phone Number *
Are there any medical conditions we should be aware of? *
Required
If yes, please explain
Drivers License/Permit Number *
Issuing State *
Expiration Date *
Has the student already taken the DMV road test and failed? *
If yes, how many times
My child has permission to ride in the vehicle with the instructor alone? *
If your child cannot ride with the instructor alone, who must accompany them during their lesson?
Preferred Driving Times: *
Required
How did you hear about me? *
How many driving hours? *
Payment *
I have read the following statement: Instruction in the car is a one-on-one activity unless your son or daughter prefers to be with another student driver. The student will be driving on the streets in Springfield and surrounding areas. The student may be picked up at home, school, or a neutral location, depending on the parent's preference. *
Today's Date *
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DD
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YYYY
Parent/Guardian Name - Signature *
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