Teen Driver Inc. Driver Registration Form

Cost $340

LYNS - See schedule online for class location.
 
 (Check class you would like to attend)
 Class Dates Class Times
(Fall Semester 16-2017 School Year)
LYNS-7-Revised Sat/Sun: 11/05/16 – 11/20/16

(Sat. classes) 8:00 - 11:00 AM 
(Sun classes) 5:00 - 8:00 PM
(weekday classes 6:00-9:00 PM)

 

(Spring Semester 16-2017 School Year)

LYNS-8 Days vary see schedule: 03/21/17 – 04/10/17

(Sat. classes) 9:00 - 12:00 AM 
(Sun classes) 5:00 - 8:00 PM
(weekday classes 6:00-9:00 PM)

 
(Summer 2017)
Classes can be taken at the Pella, Montezuma or Grinnell location or contact Teen Driver Inc. about custom classes.

Drive times may start two weeks before class starts and end 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 $140.00 registration fee to:
Teen Driver, Inc., PO Box 55, 3420 SE Powers Drive, Runnells, IA 50237
Please call us at (515) 729-3414 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. Return this form to the above address with the registration fee. The remainder of the fee ($200) is due at the first class.

(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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