Driver Education Registration Form - Jordan …

1 Driver Education Registration form Complete section 1 and return to Driver Education main office Fax: 980-343-6044 or Scan and e-mail to SECTION 1: Full name as it appears on your birth certificate (PLEASE PRINT): _____/_____/_____ (First) (Middle) (Last) Street Address_____ City_____ State_____ Zip Code_____ Home Telephone #_____ Parent s Work#_____ E-mail Address_____Cell Phone #_____ Birthdate (M)_____ (D)_____ (Y)_____ Sex: M F CMS Student ID # _____ (Circle one) (Print Clearly) School you presently attend_____ Race: B / W / A / H / I / O (Circle one) Driver Education Class Location_____ Class Instructor_____ Class Beginning Date_____/_____/_____ Ending Date_____/_____/_____ Classroom Instructor (Circle if presented) 1.

2 Birth Certificate Yes No 2. Completed Restricted Instruction Permit (eye check) Yes No 804 Issued_____ 3. Book turned in ($ charge if not turned in) Yes No Paid $_____ 4. Medical Problem No Yes If Yes, please explain_____ I have received my thirty (30) hours of Driver Education classroom training from the Charlotte-Mecklenburg School System. _____/_____ (Student Signature) (Instructor Signature) Classroom Grade P / F / D - If failed, give reason: BEHIND-THE-WHEEL INSTRUCTION BTW Beginning Date_____/_____/_____ Ending Date_____/_____/_____ I have received my six (6) hours of Driver Education BTW training from the Charlotte-Mecklenburg School System.

3 _____ / _____ (Student Signature) (Instructor Signature) BTW Grade P / F / D - If failed, give reason: SCHEDULING CALLS MADE Date_____/_____/_____ Comment_____ Date_____/_____/_____ Comment_____ Date_____/_____/_____ Comment_____ Date_____/_____/_____ Comment_____