Beginner Course Enrollment

Please complete the form as completely as possible to start your enrollment in our school.

Class Date and Program Selection

Saturday | Feb 1, 2025 | Beginner B

Student Information

First name

Middle Name

Last name

Goes by?

Street Address

Apt

High School

Neighborhood

City

State

Zipcode

Student Email

Student Phone No Dashes

Birthdate

SC Permit/License #

Permit/License Issue Date

Permit has been renewed

Select Gender

Guardian Information

Guardian Name

Guardian Phone No Dashes

Guardian Email

Guardian #2 Name

Guardian #2 Phone No Dashes

Guardian #2 Email

Living With

Mom

Dad

Other

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

Signer must be 18+ years old

Please sign below