Teen Driver Inc. Driver Registration Form

COST $325

  • WHS -  Classes held in the Junior High Art Room, on the west side of the High School in Winterset, Iowa, check with school to verify class room and location.

 (Check class you would like to attend)
 

Class

Dates Class Times
(Fall Semester 16-2017 School Year)
WHS-20 Tue/Sat: 9/13/16 –10/18/16  Vary, see schedule
(Spring Semester 16-2017 School Year) - FULL
Class days and times vary, see schedule.
Classes will run through Winterset spring break.
WHS-21 Mon-Sat 03/13/17 –03/25/17
(Days vary, see schedule)
Vary, see schedule
(Summer 2017
WHS-22 Mon-Sat: 06/05/17 –06/15/17 Vary, see schedule
WHS-23 Mon-Sat: 07/06/17 –07/17/17 Vary, see schedule
Drive times may continue for up to two weeks after last class.

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:
Confirm
Reminder

Comments:

Do you qualify for fee waiver?
full
partial

Check one; please attach waiver
form from school district for proof.


 

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 Winterset 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 Winterset School District send the deposit with form with balance ($75) due at first class. Under comments above check if you qualify for full or partial fee waiver at the Winterset School. 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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