Please return this form along with the $125.00 registration fee to: Teen Driver Inc., PO Box 55, 3420 SE Powers Drive, Runnells, Iowa 50237 The remainder of the fee ($200) is due at the first class.
Please call us at (515) 729-3414 or (515) 559-4762 for more information, questions or concerns. Please note your session dates and times on your calendar. Confirmation will be made by email, phone or post card one week prior to class start date. No refunds after first class session.
(Please print complete name and physical street address clearly. This information will be used to type up your certificates)
Student InformationEmail Address
School attended this year
In Case of Emergency Contact
Does the student have any physical or learning disabilities? Yes
If yes, please explain on back of page.