Teen Driver Inc. Driver Registration Form

COST $340

  • HHS – Classes held at Humboldt High School, Humboldt, IA, in room 22 (The College Room).
(Check class you would like to attend)
 Class Dates Class Times
(Fall Semester 16-2017 School Year) - FULL
HHS-14
Full
Wed/Sat: 11/09/16 – 12/17/16 (Wed) 6:00 – 9:00 PM
(Sat) 7:30 – 10:30 AM
(Spring Semester 16-2017 School Year) - FULL
HHS-15 Tue/Thu/Sat: 03/14/17 – 04/13/17 5:30 – 8:30 PM
(Summer 2017)
HHS-16 Mon-Sat: 05/30/17-06/10/17 7:00 – 10:00 AM

Drive times may start before class starts and continue for up to two weeks after last class.

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Office Use Only

Date: _________________
Check #: ______________
Amount: ______________

Confirm:  
Reminder:

Comments:

 

 


 

Please return this form along with the $140 deposit/registration fee to: Teen Driver Inc., PO Box 55, Runnells, IA 50237.
The remainder of the fee ($200) is due at the first class. Students that qualify for full fee waiver verified by the Humboldt School District need to send no money with form, all fees are paid by the District. Students that qualify for partial fee waiver verified by the Humboldt School District send the deposit ($140) with form with balance ($30) due at first class. Remaining balance will be paid by the District. Under comments above check if you qualify for full or partial fee waiver with the Humboldt School District. Out of district cost is $340 follow instructions above for payment.

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 or a current IEP, 504 plan, or a language barrier
that may require special accommodations as part of their education program?  Yes No
If yes, please explain on back of page.

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