In Car: *per demand

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CARMEL CENTRAL SCHOOL DISTRICT DRIVER EDUCATION PROGRAM APPPLICATION Carmel High School 30 Fair St. Carmel, NY 10512 (845)225-8441 X402 COURSE COST: $460 Student Information – All fields must be completed. Please print legibly. PRINT (FULL LEGAL NAME) MALE ( ) FEMALE ( ) ____________________________________________________________________ ______________________ LAST FIRST MIDDLE DATE OF BIRTH ____________________________________________________________________ ______________________ HOUSE/APT. NO STREET HOME PHONE ____________________________________________________________________ ______________________ CITY STATE ZIP PARENT E-MAIL ADDRESS ____________________________________________________________________ ______________________ PERMIT/LICENSE NUMBER (9 DIGIT # AT THE TOP OF LICENSE/PERMIT) ISSUE DATE

In Car: *per demand*

Car A: 7:00-8:30

Car B: 8:30-10am 10-11:30 All in Lecture Car C: 11:30-1:00 Car D: 1:00-2:30 Car times are given out at orientation. First registered, first choice, so register early. *off 4th of July: make up June 29th Friday for both Car & Lecture *Must be 16 and have permit by Monday June 25, 2018

Parent/Guardian Information & Consent I give my child permission to be enrolled in the aforementioned Driver Education program.

_______________________________ _________________________________ ___________ ________________ Parent/Guardian (Print name)

Parent/Guardian (Signature)


Patent’s Cell Phone

EMERGENCY CONTACT/MEDICAL INFORMATION: NAME:______________________________ Phone:_______________________ Alternate Phone_______________________ Doctor:______________________________ Phone:_______________________ Insurance____________________________ Policy #_____________________________ Allergies & Medications:______________________________________________ Medical/Behavioral issues related to driving:__________________________________________________________________

PAYMENT INSTRUCTIONS: ALL CHECKS/MONEY ORDERS SHOULD BE MADE PAYABLE TO: CARMEL CENTRAL SCHOOL DISTRICT (place in memo- Drivers Ed.) _________________________________________________________________________________________________________ FOR OFFICE USE ONLY: Payment Information: ___ cash ____ check#_____________ Date: ________________________

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