Over 19 Years Old Application - Alert Driver Training of Vinton

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					Alert Driver Training of Vinton                                                          www.alertdrivertraining.com
                            Application for Instruction for Students over 19
(Note to applicant: Attendance at a driver training school is NOT required for persons over 19 years of age in order to obtain a
driver’s license.)


Student Name:_________________________________________________D.O.B.___________________
                         Last                      First         Middle Name


Home Address:_____________________________________________Home Phone:_________________
                                          Street


 __________________________________________________Student Work Phone:_________________
                City                  State                Zip




Learner’s
Permit: Yes            No       _________________________________Issue Date:______________________
                                 Permit No. (required if issued)                   required
                             If no, do you require tutoring for the learner’s test?


                                    Answer following questions by marking Yes or No

1. Has student experienced a physical, mental or visual illness, injury, or condition that may affect the student’s
   ability to operate a motor vehicle during instruction, routine, or heavy traffic conditions? Yes       No

2. Has student experienced a blackout, seizure, loss of consciousness, or syncopy?                            Yes       No

3. Does student take any medication/drug prescribed by a physician or otherwise on a regular
   basis that would impair his/her ability to drive?                                                          Yes       No

4. Is the student’s privilege to drive or eligibility to obtain a Virginia instructional permit
   or Driver’s License prohibited, suspended or revoked by any court or the Department of
   Motor Vehicles?                                                                                            Yes       No

5. Has student experienced any reading or learning disability?                                                Yes       No

6. Has student experienced signs of anxiety or is overly fearful of driving or taking this course
   Or does student have any other special needs? Note: Making the instructor aware of anxiety,
   fear, or special needs will enable instructor to work more effectively with the student.       Yes                   No

    If yes, please list:__________________________________________________________________________
    _________________________________________________________________________________________________________

7. If you have a learner’s permit, have you ever driven?                                                       Yes      No
   If yes, how many hours have you driven? __________________________

I certify that all the information given in this application is true to the best of my knowledge and belief.


Signature: ______________________________________________________              Date:___________________
                                                                                                                   Page 2 (Adult) – ADT Copy


                                                      Instructional Agreement

Alert Driver Training of Vinton                        was founded to teach the latest defensive driving techniques and to enhance driver
awareness of risks faced while driving. We are dedicated to a quality educational program and making Virginia a safer place to live. In
keeping with our educational principles, Alert Driver Training of Vinton, assures the following:

The course curriculum is presented by instructors licensed by the Virginia Department of Motor Vehicles.

The Driver Education Program is State approved and meets or exceeds standards set by the Virginia
Department of Education and the Virginia Department of Motor Vehicles.

Textbooks, course materials, a dual control vehicle with a brake pedal on the right-hand side for the
instructor’s use, and is equipped with restraint systems, extra rear view mirrors, and rooftop and rear signs
are provided.

Alert Driver Training will not give the final road test to obtain a valid Virginia driver’s license. This test
will have to be taken at a Virginia Department of Motor Vehicles office and the client may elect to use the
Alert Driver vehicle to take the road test portion of the Virginia State Driver’s License Examination at no
additional charge.

                                                        Client Agreement
The client certifies that all information contained in the application for instruction is true and accurate to the best of his/her knowledge,
and that the application is a request for the client to enroll in the In-Car Driver Training Program.

The client fully understands and agrees that attending the course of instruction does not constitute successful completion nor does it
guarantee any client a Virginia State Driver’s License. All academic standards and licensing requirements must be met as set by the
Virginia Department of Education and the Virginia Department of Motor Vehicles to successfully complete the course and/or obtain a
Virginia Driver’s License.

The client agrees that in the event of a medical emergency, any instructor or agents of Alert Driver Training of Vinton may authorize
medical treatment by a proper medical facility, hospital, physician, etc. if the client is physically unable to authorize medical treatment for
him/herself.

The client fully understands that any intentional dangerous act in the nature of horseplay, prank, willful misconduct or class disruptions
are grounds for immediate expulsion without refund.

The client fully understands and agrees that no client is to be in a driver training car with the motor running or with the keys in the
ignition switch unless accompanied by a Certified Alert Driver Training of Vinton instructor.

The client fully understands and agrees that successful completion of the Alert Driver Training of Vinton Behind-the-Wheel course
does not imply that the client is an accomplished driver. No one can be considered a skilled driver until he/she has driven for
several years.




                                                            Terms of Agreement
_____The client agrees to pay $ 30.00 per hour for practice instruction
(classroom and/or behind-the-wheel which is due and payable at each session or
as a single payment for all lessons.)

_____ The client agrees to pay $30.00 per hour for tutoring services for obtaining
Virginia Learner’s Permit.

_____ The client needs 36 hours classroom instruction – cost is $200


I have read and fully understand all parts of this agreement.


Client:_________________________________________________________________Date:_________________

Address:_____________________________________________________________________________________

Parent/Guardian:_________________________________________________________Date:_________________

Relationship to client:____________________________________________________

Address if different than client:___________________________________________________________________

____________________________________________________________________________________________



Alert Driver Training of Vinton Representative:

______________________________________________________________Date:_______________

Under no circumstances will a student be allowed to drive on the school’s property while using a learner’s permit unless there is an authorized
adult with him/her in the vehicle.

We STRONGLY discourage clients to drive anywhere or anytime without a licensed authorized adult in the vehicle with them.


(Revised 6/09)
                                                                                                              Page 3 (Adult) – Customer Copy


                                                      Instructional Agreement

Alert Driver Training of Vinton                        was founded to teach the latest defensive driving techniques and to enhance driver
awareness of risks faced while driving. We are dedicated to a quality educational program and making Virginia a safer place to live. In
keeping with our educational principles, Alert Driver Training of Vinton, assures the following:

The course curriculum is presented by instructors licensed by the Virginia Department of Motor Vehicles.

The Driver Education Program is State approved and meets or exceeds standards set by the Virginia
Department of Education and the Virginia Department of Motor Vehicles.

Textbooks, course materials, a dual control vehicle with a brake pedal on the right-hand side for the
instructor’s use, and is equipped with restraint systems, extra rear view mirrors, and rooftop and rear signs
are provided.

Alert Driver Training will not give the final road test to obtain a valid Virginia driver’s license. This test
will have to be taken at a Virginia Department of Motor Vehicles office and the client may elect to use the
Alert Driver vehicle to take the road test portion of the Virginia State Driver’s License Examination at no
additional charge.

                                                        Client Agreement
The client certifies that all information contained in the application for instruction is true and accurate to the best of his/her knowledge,
and that the application is a request for the client to enroll in the In-Car Driver Training Program.

The client fully understands and agrees that attending the course of instruction does not constitute successful completion nor does it
guarantee any client a Virginia State Driver’s License. All academic standards and licensing requirements must be met as set by the
Virginia Department of Education and the Virginia Department of Motor Vehicles to successfully complete the course and/or obtain a
Virginia Driver’s License.

The client agrees that in the event of a medical emergency, any instructor or agents of Alert Driver Training of Vinton may authorize
medical treatment by a proper medical facility, hospital, physician, etc. if the client is physically unable to authorize medical treatment for
him/herself.

The client fully understands that any intentional dangerous act in the nature of horseplay, prank, willful misconduct or class disruptions
are grounds for immediate expulsion without refund.

The client fully understands and agrees that no client is to be in a driver training car with the motor running or with the keys in the
ignition switch unless accompanied by a Certified Alert Driver Training of Vinton instructor.

The client fully understands and agrees that successful completion of the Alert Driver Training of Vinton Behind-the-Wheel course
does not imply that the client is an accomplished driver. No one can be considered a skilled driver until he/she has driven for
several years.




                                                            Terms of Agreement
_____The client agrees to pay $ 45.00 per hour for practice instruction
(classroom and/or behind-the-wheel which is due and payable at each session or
as a single payment for all lessons.)

_____ The client agrees to pay $25.00 per hour for tutoring services for obtaining
Virginia Learner’s Permit.


I have read and fully understand all parts of this agreement.


Client:_________________________________________________________________Date:_________________

Address:_____________________________________________________________________________________

Parent/Guardian:_________________________________________________________Date:_________________

Relationship to client:____________________________________________________

Address if different than client:___________________________________________________________________

____________________________________________________________________________________________



Alert Driver Training of Vinton Representative:

______________________________________________________________Date:_______________

Under no circumstances will a student be allowed to drive on the school’s property while using a learner’s permit unless there is an authorized
adult with him/her in the vehicle.

We STRONGLY discourage clients to drive anywhere or anytime without a licensed authorized adult in the vehicle with them.


(Revised 6/09)

				
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