TEEN DRIVER ED SIGN-UP

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Parent/Guardian Information:

First and Last Name of Parent or Guardian completing this form:

Parent or Guardian: E-mail address:

Student Information: (Legal name including any suffixes, e.g. Jr. or III)

Legal First Name:

Middle Initial:

Legal Last name including any suffixes, e.g. Jr. or III:

Nickname (if other than legal name): (for our name tents in the class)

Gender:

Female
Male

Street Address:

PO Box (if any):

City:

ZIP:

Home Phone #

Emergency Contact Phone #:

Emergency contact Name:

Emergency Contact Relationship to student:

Student Date of Birth: ex.: MM/DD/YYYY

High School:

Class Date you wish to attend: Select one... September 15, 2008 September 29, 2008 October 13, 2008 October 27, 2008 November 10, 2008

Parent: Have you attended a previous Orientation session with another child?

YES
NO
(You will receive more information regarding Oriention with your confirmation email).

Anything else you would like us to know, any questions, or to be on the wait list please enter here:

IMPORTANT: You will receive a confirmation email from us within 3 business days with more information for you regarding the class. YOU MUST call us If you do not receive this email.

Thank you for choosing Officers Driving School!

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