Instructor Certification Course Registration

1/2 fee ( $600.00 ) is due the first day of class, final payment due the last day of class.
Please submit the form below and we'll have an instructor contact you to set up your course dates.

Upon enrolling, an instructor will contact you with 48 hours to schedule a class.

Student Information

First name

Middle Name

Last name

Goes by?

Street Address

Apt

City

State

Zipcode

Student Email

Student Phone No Dashes

Birthdate

Select Gender

Driving School Information

Driving School Name

Driving School Phone No Dashes

Driving School Contact

Student Medical Information

Does the student wear glasses / contacts?

Wears Glasses

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

Autism / Asperger's

Comments

Printed Signature

Signer must be 18+ years old

Please sign below

By clicking the "Submit Enrollment Securely" button, I am agreeing to the following Enrollment Terms and Conditions