STUDENT REGISTRATION FORM
DATE
*
/
Month
/
Day
Year
Date
Name
*
FIRST NAME
LAST NAME
STREET ADDRESS
*
CITY
*
STATE
*
ZIP CODE
*
HOME PHONE
STUDENT CELL PHONE
*
EMERGENCY CONTACT
*
PHONE
*
STUDENT EMAIL ADDRESS
*
Confirmation Email
example@example.com
DATE OF BIRTH
*
/
Month
/
Day
Year
Date
PERMIT #
IF YOU HAVE ONE
PERMIT-DATE ISSUED
/
Month
/
Day
Year
Date
DO YOU WEAR CORRECTIVE LENSES FOR DRIVING
*
HIGH SCHOOL
*
DO YOU HAVE ANY PHYSICAL CONDITION REQUIRING SPECIAL EQUIPMENT WHILE DRIVING?
*
Please Select
YES
NO
IF YES PLEASE EXPLAIN:
DO YOU HAVE ANY SPECIAL LEARNING NEEDS?
*
Please Select
YES
NO
IF YES, PLEASE EXPLAIN:
DO YOU TAKE ANY MEDICATIONS REGULARLY THAT COULD AFFECT YOUR DRIVING?
*
Please Select
YES
NO
IF YES, PLEASE LIST MEDS:
HOW DID YOU HEAR ABOUT US
APPLICANT SIGNATURE
*
WELCOME TO HOFFMAN AUTO SCHOOL!!!!
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