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 $150.00 on the next form or your enrollment may be discarded.

Program Selection

Program Level

Student Information

First name

Middle Name

Last name

Goes by?

Street Address

Apt

Neighborhood

City

State

Zipcode

Student Email

Student Phone No Dashes

Birthdate

SC Permit/License #

Permit/License Issue Date

Permit has been renewed

Select Gender

Addtional Information

College

Home Phone No Dashes

Other Phone No Dashes

Emergency Contact Information

Contact #1 Name

Contact #1 Phone No Dashes

Contact #1 Email

Relation to Student?

Contact #2 Name

Contact #2 Phone No Dashes

Contact #2 Email

Relation to Student?

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

Comments

Printed Signature

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