HOFFMAN STUDENT PROFILE CARD

NAME*
(Full Legal Name)
Date of Birth*

MonthDayYear
Date
PERMIT#
If You Have One
Date of Permit

MonthDayYear
Date
YesNo
Mom's HouseDad's HouseOther
Location 1 Label
Location 2 Label
Address (Primary)*

Street Address

Address Line 2

CityState

Zip
Mom's HouseDad's HouseOther
Address (Secondary)

Street Address

Address Line 2

CityState

Zip
STUDENT CELL PHONE*
Format: (000) 000-0000.
PARENT/GUARDIAN CELL PHONE #*
Please enter a valid phone number.Format: (000) 000-0000.
HIGH SCHOOL*
STUDENT EMAIL*

Confirmation Emailexample@example.com
YESNO
Please List Allergies:
ALERGIC TO
YESNO
ANXIETYDEPRESSIONAUTISM SPECTRUM DISORDER (ASD)ASPERGERSADHD (ADD)Other
Orange Dot

CLASSROOM INFORMATION & MODULES
IN-PERSONREMOTE
If Your Parents Took the Parent Class, Who Attended the Class?
If you are not 100% sure, leave blank and it can be filled in later.
When Did They Take the Parent Class?

MonthDayYear
if not 100% sure, please leave blank
classroom type*
Classroom Modules Attendance Information

Please Double Check the Pre-Filled Information Below. If Correct, Submit your Form
MOD 1. INTRO TO DRIVER'S ED. :   *      *
MOD 2. SIGNS-SIGNALS-RD MARKS. :   *   *
MOD 3. VEHICLE AND IT'S CONTROLS:   *   *
MOD 4. BASIC DRIVING SKILLS:   *   *
MOD 5. RULES OF THE ROAD:   *   *
MOD 6. MAKE SAFE DRIVING DECISIONS:    *    *
MOD 7. SHARING THE ROAD   *   *
MOD 8. NATURAL LAW AND DRIVING:   *   *
MOD 9. DIFF DRIVING ENVIRONMENTS:   *   *
MOD 10. DRIVING IN ALL WEATHER COND:    *     *
MOD 11. MENTAL & PHYS EFFECTS DRIVING  *   *
MOD 12. DANGERS OF ALCOHOL-DRUGS   *   *
MOD 13. DISTRACTED DRIVING   *   *
MOD 14. UNSAFE DRIVING-POOR DECISIONS   *   *
MOD 15. EMERGENCIES AND BREAKDOWNS    *   *
MOD 16. LEAVE THIS AREA BLANK
MOD 17. FINAL EXAM DATE TAKEN | SCORE *
Should be Empty: