- Behind the Wheel Charleston

Student Information

First Name

Middle Name

Last Name

Goes by?

Street Address

Apt

High School

Neighborhood / Subdivision

City

State

Zipcode

Student Email

Phone

Birthdate

SC Permit/License #

Permit/License Issue Date

Issue Date of Renewal Permit (if renewed)

Gender

Guardian Information

Guardian #1 Name

Guardian Phone

Guardian Email

Guardian #2 Name

Guardian #2 Phone

Lives with?

Mom

Dad

Other

Student Medical Information

Does the student wear glasses / contacts?

Yes

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, or leave blank if none)

Paralysis

Hearing Difficulties

Heart Trouble

Seizures

Perception Difficulties

Epilepsy

Orthopedic Difficulties

Comments

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