MARYLAND DEPARTMENT OF TRANSPORTATION
Behind The Wheel Student Record
Name: (As it appears on Learner's Permit)
*
First Name
Middle Name
Last Name
Phone #
*
Format: (000) 000-0000.
Street Address
*
City
*
County
*
State
*
Zip Code
*
Student Email
example@example.com
Name of Driving School
Branch
School Number
Date of Birth
*
/
Month
/
Day
Year
Student Age
*
Permit Number (Customer Identifier)
*
NO SPACES or DASHES
Driving Appointments
Enter Student Driving Hours Below
Appointment 1
Appointment 2
Appointment 3
Hours
Hours
Hours
Date Appointment 1
*
/
Month
/
Day
Year
Date
Appointment 1 Time
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Lesson 1 Comments
Lesson 1 Performance
*
Please Select
1
2
3
4
5
Date Appointment 2
*
/
Month
/
Day
Year
Date
Appointment 2 Time
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Lesson 2 Comments
Lesson 2 Performance
*
Please Select
1
2
3
4
5
Date Appointment 3
*
/
Month
/
Day
Year
Date
Appointment 3 Time
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Lesson 3 Comments
Lesson 3 Performance
*
Please Select
1
2
3
4
5
Tag Number
*
Instructor Initials
*
Instructor ID #
*
E-Signature
Date
/
Month
/
Day
Year
Date
Date
*
/
Month
/
Day
Year
Date
Student Evaluation
Instructor must evaluate the student performance below.
Instructor Name
*
Evaluation (Check all that have been completed successfully)
*
Pre-Entry
Enter and Secure
Adjustments
Starting Tasks
Basic Vehicle Control
Head Checks
Staggered Stops
Lane Selection
Lane Position
Cornering
Following Distance
Right of Way
Turn Signal Use
Traffic Sign Awareness
Traffic Signal Awareness
Left Turns
Right Turns
Lane Changes
Merge
Risk Awareness
Backing
3 Point Turn
2 Point Turn
Parallel Park
Perpendicular Park
Final Score
Parent Ride Along
*
Yes or No
Debrief
*
Yes or No
Final Score
*
Please verify that you are human
*
Student Signature
Instructor Signature
Date
*
/
Month
/
Day
Year
Date
Date
*
/
Month
/
Day
Year
Date
Lesson Grade
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