PRECISION DRIVER TRAINING SCHOOL
APPLICATION FOR DRIVER EDUCATION
Please print clearly.
LEGAL NAME: / /
Last First Middle Date of Birth
Street City, State Zip
PERMIT # Age as of course ending date
Person for Emergency Contact Ph.#
Please circle any physical/medical conditions that apply:
Hearing Problems Vision Problems DiabeteDiabetes
Rheumatic Fever Orthopedic Problems AAsAsthmAsthma
Chronic Illness Allergic Reactions EpilEpilepsEpilepsy
Fainting Spells Cerebral Palsy H e H e a H e a r Heart
List any medications the applicant takes regularly.
ListList any learning challengesList any learning challenges that you believe the instructor should be aware o
I certify that I have no other conditions that may place myself or others at risk of injury.
Applicant Signature Parent/Guardian Signature Date
(If applicant is less than 18 years old)
PleasePlease circle the location you plan to attend. Course beginning date:_______________
Morrisville Barre Irasburg Winooski Rutland Newport
Please return to: Precision Driver Training School
900 Rt. 58 West
Irasburg, VT 05845
Refund Policy: Refunds are available to students who pay Refunds are available to students who pay the ful
to the first class. Withdrawals prior to the first classto the first class. Withdrawals prior to the first class will
aa $100 administrative fee. Refunds for withdrawals after the firsta $100 administrative fee. Refunds for w
atat 6% of the tuition for eachat 6% of the tuition for each class day beginningat 6% of the tuition for each class
on the last class day.