Teen Driver Inc. Driver Registration Form

Clarke students register through High School office all others fill out this form and send it to the address listed on this form.

Clarke District Students check with High School Office for Cost of Program

Students out of district cost of $325

 

  • OCHS- Classes to be held at the Clarke High School, 802 North Jackson,
    Osceola, Iowa

 (Check class you would like to attend)
 

Class

 Dates Class Times
(Fall Semester 12-2013 School Year)
OCHS-11

Mon/Wed: 9/17/12 – 10/17/12          

3:30 – 6:30 PM
(Spring semester 12-2013 School Year)
OCHS-12 Mon/Wed: 03/25/13– 04/24/13 3:30 – 6:30 PM
(Summer 2013)
OCHS-13 Mon-Fri: 06/03/13 – 06/14/13 8:00 – 11:00 AM

Page 1 of 1

Office Use Only
Date: _________________
Check #: ______________
Amount: ______________

Free/Reduced Status:
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 or (515) 559-4762 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.

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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