Next Class Starting October 17th
FULL NAME OF STUDENT First_________________Middle________________Last_______________ Address______________________________________________________ City_______________________________Zip Code__________________
School Attending_________________________________Home School____ High School____________________Middle School___________________
Phone____________________________ Cell Phone____________________________
Date of Birth___________________________
Social Security Number______________________________________________
PARENT OR GUARDIAN INFORMATION
Name_____________________________________________ Address___________________________________________ City_________________________________Zip Code_____________________
Work Phone___________________________ Home Phone__________________________ Cell Phone____________________________
Parent or Guardian Signature_____________________________________Date______________________
EMERGENCY CONTACT Doctor________________________________Phone__________________ Hospital_______________________________Phone__________________
Does the student have any disabilities? If so, please explain_______________________________________________________________
Does the student have any special needs or modifications that are part of his or her educational program?________________________________________________________________________________________
Please mail the registration fee, this form, and a photocopy of your driving permit to:
Drive Pro, Inc.
Mikel W. Ghere
4791 Roseman Drive
Clear Lake, Iowa 50428
Please call 641-420-5822 if you have any questions.
Cost is $330. Payment can be made in cash, credit card, or check payable to Drive Pro, Inc. The cost can be made in two installments. 1st payment is due with registration form; 2nd payment is due two weeks after starting date. There is a $11 service charge for credit card transactions. Certificate will be issued 30 days after personal check if received. Payment for the class tuition will not be dependent on the student passing the class. Missed driving classes will cost $25 if not cancelled the evening before. Each student will be presented a white certification slip at the end of the course. If this slip is lost, it will cost $25 to have a new one issued. There will be no refund after the first class has started.
Please call 641-420-5822 if you have any questions. We are looking forward to serving you.