Remote Class Enrollment Form - Driving School of North Texas

Remote Class Enrollment

Student Information
Legal First Name*
Parents Email*
Enter Email Confirm Email
Middle Initial*
Students Cell*
Legal Last Name*
Parents Cell*
High School*
XXX
Birthday*
Month
Day
Year
Other Phone
Sex*
- Male
- Female
Address*
Street Address City State ZIP Code
Fees & Services
Services
Services
- Remote Driver Education Class (24 hours Classroom & 7 two hour driving lessons.)
Other Services
Other Services
- Remote Classroom Instruction Only (32 hours)
Total
Remote Class Enrollment
Start Date*
MM slash DD slash YYYY
Start Time*

: Hours

Minutes
Select School Location
School may terminate Student’s enrollment if Student accumulates absences in excess of 5 days of scheduled classroom hours. Driver Permit may be revoked if classroom is not completed within two hundred ( 240) days. The Parent and Student agree that all classroom and in-car lessons must be made-up/completed within the 240 days of the classroom beginning date.
Initials*
I agree to the terms and Conditions*
- Yes
- No
Signature*
Disclosure
Medical Condition*
Does your student currently have or had ever been diagnosed with or treated for any medical condition that may affect his/her ability to safely operate a motor vehicle?
Hospitilization*
Within the past two years, has your student been diagnosed with, been hospitalized for or currently being treated for a psychiatric disorder? Examples included but not limited to ADHD, ADD, epileptic seizure, convulsion, loss of consciousness or other seizure.
If Yes, please explain
Payment Details
Card Number
Payment Form
Expiration Date
Security Code

Remote Class Enrollment

Student Information

Fees & Services

Remote Class Enrollment

Disclosure

Payment Details