Class Date and Program Selection

Student Information

Addtional 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)

Not Diagnosed
Paralysis
Hearing Difficulties
Heart Trouble
Seizures
Perception Difficulties
Epilepsy
Orthopedic Difficulties

Comments


Payment Information
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