Segment 1 Enrollment

Which class dates are you enrolling for?

Your Name *

Student's First Name *

Student's Last Name *

Address 1 *

Address 2

City *

State

Zip / Post Code *

Student's Date of Birth *

Email *

Phone *

Does the student require any special accommodations to participate in the classroom phase? (i.e., test being read to him/her, an interpreter, seating arrangements, etc.)? *

Yes
No

If Yes, please explain:

Does the student require any special accommodations to participate in the behind-the-wheel phase? (i.e. adaptive devices, an interpreter, etc.)? *

Yes
No

If Yes, please explain:

Is the student taking any medications that may affect his/her ability to drive a motor vehicle safely? *

Yes
No

If Yes, please describe:

Are there any medical conditions that would pose a concern with the student's behind-the-wheel instruction (epilepsy, asthma, color blindness, hearing loss)? *

Yes
No

If Yes, please explain:

Is the student's visual acuity at least 20/40 corrected? *

Yes
No

In the last six months, has the student had a fainting spell, blackout, seizure, or uncontrolled loss of consciousness? *

Yes
No

In the last six months, has the student had a physical or mental condition which affected his/her ability to drive a motor vehicle safely? *

Yes
No

I certify that the information on this form is true and accurate to the best of my knowledge. *

ELECTRONIC SIGNATURE