Keys 4 Safe Driving Registration Form

Louisiana Department of Public Safety and Corrections
DRIVER EDUCATION REGISTRATION AND COURSE FORM
DRIVING SCHOOL INFORMATION
KEYS 4 SAFE DRIVING SCHOOL. LLC-1205

1910 OAK PARK BLVD. LAKE CHALES, LA, 70601

COURSE INFORMATION- check the course requested
Driver Education

Classroom - 6 hours BTW - 8 hours (14 hour) Classroom - 30 hours BTW - 8 hours (38 hour) Behind The Wheel Only - 8 hours
Date of Enrollment

Month Day Year
Date
STUDENT INFORMATION
Name of Student (PRINT First/Middle/Last)
*PLEASE FILL OUT THE STUDENT'S FIRST, MIDDLE, AND LAST NAME*
TIP #:
TIP Issue Date

Month Day Year
Date
Address

Home Address

Street Address Line 2

City State

ZIP Code
Date Of Birth

Month Day Year
Date
AGE
Grade
High School Attending (Must be in at a minimum in the 8 grade)
CONTACT PHONE NUMBERS
Home Phone
Parent’s Cell
Student Cell
Email:
STUDENT’S DRIVING EXPERIENCE
Describe locations where you have driving experience. Check all that apply

None Subdivision Parking Lots Rural Roads In Town Highway Interstate
PARENTAL/GUARDIAN CONSENT- TO BE COMPLETED IF STUDENT IS A MINOR
I do hereby certify that I am the Legal Parent/Guardian of the minor applying and this is my authorization to the above named Driving School to administer the driver education course indicated above. I also declare by my signature below that the information I provided is complete and accurate.
Signature of Legal Parent/Guardian

Clear
Date

Month Day Year
Date
Classroom Course Dates
Should be Empty:

Louisiana Department of Public Safety and Corrections