Teen Driver Inc. Driver Registration Form

COST $325

Newton classes are custom classes only at this time; contact Teen Driver, Inc. to see what it takes to get this going. Anyone can sign up for the custom classes listed. Classes are also offered at different city locations around Newton, check web site for a location nearest you. These are the custom classes we have so far.

NHS – All classes to be held at a location in Newton check class schedule to find out where custom class will be held.

(Check class you would like to attend)
Class Dates Class Times
(Newton fall semester 15-2016 school year)
No custom classes at this time
(Newton spring semester 15-2016 school year)
No custom classes at this time
 
(Newton summer 2016)  
NHS-8  Mon-Fri: 05/16/16 – 06/06/16 Class days and times vary see schedule online  
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:

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.

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.

(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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