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STUDENT REGISTRATION FORM

14-Hour

Must be at least 18 years old. One day of classroom instruction and eight hours of behind-the-wheel driving. Official OMV Test administered at the end of the class day.

SESSION
First Name	(max 30 characters a-z and A-Z)
Middle name	(max 30 characters a-z and A-Z)
Last name	(max 30 characters a-z and A-Z)
TIP #	(You may register without your TIP #; however, the TIP # must be obtained from the DMV prior to the first day of class. See TIP FAQ for more information. )
TIP Issue Date	(Must be after 09/04/2018.)
Date of Birth
Email Address
Home Phone Number	(10 digit number)
Student's Cell Phone Number	(10 digit number)
GENDER	Male Female
ADDRESS
CITY	(max 30 characters a-z and A-Z)
ZIP CODE
STATE	(max 2 characters A-Z)
Medical Questions	Does the student have any medical conditions that would pose concerns with the students behind the wheel instruction (epilepsy,asthma, colour blindness, hearing loss, etc...)? Yes No Does the student have any mental/physical impairments which could affect the ability to drive a motor vehicle safely? Yes No Has the student experienced unconsciousness other than normal sleep? Yes No Is the student's visual acuity at least 20/40 corrected? Yes No Does the student require any special accommodations to participate in this course(i.e.,oral tests,interpreter,seating arrangements,adaptive equipment)? Yes No
Student's Driving Experience	None Subdivision Parking Lots Rural Roads In Town Highway Interstate
Notes (List members of group registration or other notes for instructor.)