Teen Driver Inc. Driver Registration Form

COST $325

  • CHS - Class held in the Middle School 7th grade Geography room, 1300 North 16th Street, Chariton, IA.

 (Check class you would like to attend)
 

Class

 Dates Class Times

(Summer 2012) 

CHS-16            Mon-Sat: 05/26/12 – 06/07/12 8:00-11:00 AM

(Fall semester 12-2013 school year)    

CHS-17           Mon-Sat: 10/16/12 – 11/05/12 6:00-9:00 PM
    (Days vary see schedule) (Saturday classes ) 8:00-11:00 AM

(Spring semester 12-2013 school year)
CHS-18            Mon-Sat: 02/11/13 – 03/02/13 6:00-9:00 PM
    (Days and times vary see class schedule)                 (Saturday classes) 8:00-11:00 AM

(Summer 2013) 

CHS-19 Mon-Sat: 05/21/13 – 06/06/13 6:00-9:00 PM
    (Classes on the 21st, 23rd, and 28th)  
    (Days and times vary see class schedule)                      (All other classes)    8:00-11:00 AM
  (Summer drive times may extend at least one week past last class.)


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Office Use Only
Date: _________________
Check #: ______________
Amount: ______________

Confirm:  
Reminder:

Comments:
 

 

Please return this form along with the $125.00 registration fee to:
Teen Driver Inc., 1009 West Salem Ave., Indianola, IA 50125.
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.
Student Information                            Email Address  
First Middle Last
Street  
City  State Zip
DOB   Phone School attended this year
Parent/Guardian Information
Name Home Phone
Address Work Phone
City Zip
In Case of Emergency Contact
Name Phone
Preferred Hospital
Doctor Phone
Does the student have any physical or learning disabilities? Yes No If yes, please explain on back of page.

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