NORTHERN HUMBOLDT ADULT EDUCATION
DRIVERS TRAINING REGISTRATION FORM
Student Name: ___________________________________________________________
Birth date:________________________________ Phone: ________________________
Address:_________________________________________________________________
School of Attendance:______________________________________________________
PLEASE CHECK ONE:
________ Arcata High School _________McKinleyville High School
_________ Other
IF YOU HAVE A PREFERENCE, PLEASE CHECK BOX:
{ } Afternoon: hours to be arranged with instructor.
{
} Saturday/Sunday:
Six, TWO HOUR SESSIONS to be arranged with instructor
Four, THREE HOUR SESSIONS to be arranged with instructor
Drivers Education Completion Date: ______________
DO YOU HAVE YOUR PERMIT?: YES __________ NO___________
________________________________
Student Signature
________________________________
Parent/Guardian Signature
____________________________
Date
____________________________
Date
Emergency Contact:_____________________________________________________________
Name
Phone #
HIGH SCHOOL STUDENTS MUST MEET THESE REQUIREMENTS:
1. The student’s high school schedule meets the minimum 240/150 minutes per day
required.
Signature: Counselor/Administrator________________________________________
Receipt:
Class Fee ____________
Rec’d By_____________
Date________________
Cash _____ Check _____
Online _______________
Assigned Instructor:___________________
Date Assigned:_______________________