Behind the Wheel Registration

Please submit the form below and we'll have an instructor contact you to set up your lessons.
Student Information
Addtional Information
Emergency Contact Information
Student Medical Information

Does the student wear glasses / contacts?

Does The Student Have Any Impairment That Would Prevent Him / Her From Receiving And Applying Verbal Instruction / Direction ? If So, Please Explain:

Are There Any Conditions That We Should Know About That Could Affect A Student's Driving Capability Physically?

Does The Student Take Any Medication? If So, What Kind & What Is It For? (Please List All)

Please Let Us Know If The Student Has Ever Been Diagnosed With Any Of The Following: (Check all that apply)

Not Diagnosed
Paralysis
Hearing Difficulties
Heart Trouble
Seizures
Perception Difficulties
Epilepsy
Orthopedic Difficulties

Comments

Program Selection
Payment Information
This option is not available for this type of enrollment.
Or
A minimum payment of $200.00 is required.