Teen Driver Inc. Driver Registration Form

COST $325

APHR – Classes held at the Pleasant Hill Public Library, 5151 Maple Dr, Pleasant hill, IA, check with Library for room number.

 (Check class you would like to attend)


Dates Class Times
(Summer 2016)
APHR-1 Mon-Fri: 06/13/16 – 06/24/16 12:00-3:00 PM
Summer drive times may continue for up to two weeks after last class.         

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Office Use Only

Date: _________________
Check #: ______________
Amount: ______________

Free/Reduced Status:




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 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
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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