Teen Driver Inc. Driver Registration Form

COST $325

  • IHS - classes held at Indianola High School, 1304 East Second Avenue Indianola, IA, room 336.

(Summer 2016)
IHS-94 Mon-Fri: 08/01/16 – 08/12/16 8:00-11:00 AM
(Fall Semester 16-2017 School Year)
IHS-95 Tue/Thu: 09/13/16 – 10/13/16 5:30-8:30 PM
IHS-96 Tue/Thu: 11/08/16 – 12/13/16 5:30-8:30 PM
(Spring Semester 16-2017 School Year)
Note: No classes during the week of spring break but may be drive times if instructor and any students are interested.
IHS-97 Tue/Thu: 02/21/17 – 03/30/17 5:30-8:30 PM
IHS-98 Tue/Thu: 04/11/17 – 05/11/17 5:30-8:30 PM
(Summer 2017)
Note: If snow make-up days June class will start as scheduled but class time will be from 5:30-8:30 until school is out
IHS-99 Mon-Fri: 06/04/17 – 06/16/17 8:00-11:00 AM
IHS-100 Mon-Fri: 07/10/17 – 07/21/17 8:00-11:00 AM
IHS-101 Mon-Fri: 07/31/17 – 08/11/17 8:00-11:00 AM
Summer drive times may continue for up to two weeks after last class

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Office Use Only

Date: _________________
Check #: ______________
Amount: ______________

Confirm:  
Reminder:

Comments:

 

Fee Waiver:
free:  
reduced:

 

 

Please return this form along with the $125.00 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 Indianola 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 Indianola School District send the deposit ($125) with form with balance ($37.50) 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 Indianola School District. Out of district cost is $325 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? Yes No If yes, please explain on back of page.

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