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Individual Lessons Enrollment

Please complete the form as completely as possible to start your enrollment in our school.
You will be expected to make a minimum payment of $200.00 on the next form or your enrollment may be discarded.
Program Selection
  • 2Hr Behind the Wheel - $200.00
  • 4Hr Behind the Wheel - $400.00
  • 6Hr Behind the Wheel - $450.00
  • Yes ( +$50.00)
  • No

Student Information
  • Male
  • Female

Addtional Information

Emergency Contact 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)

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