Teen Driver Inc. Driver Registration Form

Cost $325

  • GHS – Classes to be at Gilbert Middle School, room 126.
 (Check class you would like to attend)
  Class Dates Class Times
(Fall Semester 16-2017 School Year)
GHS-11 Tue/Thu: 10/04/16– 11/03/16    5:30-8:30 PM
(Spring semester 16-2017 school year) (No classes Mar 13-17 - spring break)
GHS-12 Tue/Thu: 03/07/17– 04/13/17 5:30-8:30 PM
(Summer 2017)
GHS-13 Mon-Fri: 06/05/17 – 06/16/17 1:00 – 4:00 PM   
GHS-14 Mon-Fri: 07/6/17 – 07/19/17 1:00 – 4:00 PM   

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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., 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 for more information, questions or concerns. Please note your class 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 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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