Florida Sheriffs Association Teen Driver Challenge Online Application
Please note: Completing this application does not secure a spot in a future TDC course. Once your application is reviewed, you will receive a full registration packet via email, which must be completed and delivered prior to the application deadline.
N/A should be used in areas that do not apply to the student
STUDENT INFORMATION
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Race/Ethnicity
*
White
Hispanic/Latino
Asian
Black/African American
Hawaiian/Pacific Islander
American Indian/Alaskan Native
Other
Sex
*
Male
Female
Driver's License / Learner's Permit Information
Driver's License / Learner's Permit Number
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Contact Information
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address (If different from above)
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Cell Phone
*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
High School
*
Please Select
Flagler-Palm Coast
Matanzas
Homeschool/Other
Grade
*
Please Select
9
10
11
12
Student Email
*
example@example.com
Parent/Legal Guardian Name
*
First Name
Last Name
Parent / Legal Guardian Phone
*
Please enter a valid phone number.
Parent/Legal Guardian Email
*
example@example.com
Back
Next
Preview PDF
Submit
Are you taking medication that would affect your ability to operate a vehicle?
*
Yes
No
Are there any health issues, allergies or disabilities we should be aware of?
*
Yes
No
Class date requested
*
/
Month
/
Day
Year
Date
Class date requested
Please Select
April 12/13
County
*
Please Select
Flagler
Were you court ordered to attend?
*
Yes
No
What is your compliance date?
-
Month
-
Day
Year
Date
Number of behind-the-wheel practice hours
Shirt Size
*
Please Select
Small (S)
Medium (M)
Large (L)
Extra Large (XL)
Student Signature
*
Parent/Legal Guardian Signature
*
Should be Empty: