Driver Evaluation Registration

Please submit the form below and we'll have an instructor contact you within 48 business hours to set up your evaluation.
Evaluation Reason

Student Information

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)

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

Comments


Program Selection
Driver Evaluation - 2 Hrs Behind the Wheel evaluation - $140.00

Payment Information
This option is not available for this type of enrollment.
Or
A minimum payment of $140.00 is required.