(Spring 2016)
DRIVER EDUCATION APPLICATION
CIRCLE ONE:
SENIOR
PAYMENT REC'D ____________________
JUNIOR
DATE OF BIRTH ______ ______ ______
month
day
year
***PLEASE PRINT ALL INFORMATION BELOW***
Name must appear EXACTLY as on your PERMIT or license.
NAME ____________________________________________________________________________________________
(Last)
(First)
(Middle name or initial)
ADDRESS ________________________________________________________________________________________
__________________________________________________________________________________________________
TELEPHONE ___________________________________________ Eye Color ________________________________
CHECK ONE:
YES__ NO__
Are you taking a l0th period physical education class?
YES__ NO__
Have you been enrolled in driver ed. classes previously?
YES __ NO __
Do you receive free or reduced lunch?
ALL STUDENTS MUST HAVE A LEARNER'S PERMIT OR JUNIOR LICENSE AND BE IN GOOD ACADEMIC
STANDING (INCLUDING GRADES, ATTENDANCE and BEHAVIOR). PLEASE ATTACH A COPY OF YOUR
PERMIT OR JUNIOR LICENSE TO THIS APPLICATION.
If you attend a private or parochial school, please give the name of your school. ____________________________________
With full enrollment of students, driver education classes will be offered Monday, Tuesday or Thursday. Please note that we
can accommodate 120 students. Selection of applications will be made on a first come, first served basis, giving priority to
seniors, followed by juniors, based upon birth date. Students attend class and driving one day each week for sixteen (16)
weeks. Classes begin at 2:30 P.M. and end at 5:30 P.M.
Number the days below in the order of your preference. For example, if Monday is your 1st choice, please put a number one (1)
in the box next to Monday. Please be sure to number each day. If you do not have a preference, check the appropriate box.
For your information:
 No classes will be scheduled on
holidays.
 Cars will meet students in the south lot.


Lecture class will meet in Room 343.
Students will be dropped from the program upon the
third absence from either the car or the class.
NUMBER BOXES 1 - 3
MONDAY
TUESDAY
THURSDAY
[ ]
[ ]
[ ]
NO PREFERENCE
[ ]
**NO EXCEPTIONS WILL BE MADE FOR PARTICIPATION IN EXTRACURRICULAR ACTIVITIES (i.e.
SPORTS, CLUBS AND FIELD TRIPS.) Any student who fails to make up an absence within a month must attend an
emergency make up at the end of the course. This opportunity will be available to make up only a single absence.
Additionally, only juniors with a co-op class will be issued a school parking permit. No exceptions will be made.
Return this application to Mrs. Surico in the main office by 2:15 P.M. Friday, January 22, 2016. Classes will be posted outside
the main office Wednesday, January 27th by 2:15 P.M. You must attach a copy of your license or permit when returning this
application. The waiving or reducing of the driver education fee will take place in accordance with those pupils who receive
free or reduced lunch. Any student using the lunch waiver to apply for the driver education waiver should see Mrs. Surico in
the main office.
DRIVER EDUCATION CLASSES WILL BEGIN ON MONDAY, February 1st for students in
Monday classes, Tuesday, February 2nd for students in Tuesday classes and Thursday, February
4th for students in Thursday classes.
Dear Parent:
Please read and discuss the criteria listed below with your child prior to signing this form. It is important for
your child to understand the responsibility and ramifications that he/she is undertaking by enrolling in driver
education.
Students wishing to participate in the driver education program must return this application to the main
office with a copy of their permit, by 2:15 P.M. by Friday, January 22, 2016. Driver education
classes will start on Monday, February 1, 2016 and will end the first week of June, 2016.
Eligible pupils are those who possess a learner's permit, are in 11th or 12th grade, and are in good academic
standing. It is expected that proper footwear be worn for the driving portion of the program. Failure to do
so will result in driving privileges being denied. Students will be assigned classes based on chronological
order of their date of birth, and on a first come, first served basis. A copy of the learner's permit and
$415.00 registration fee must accompany the pupil's application at the time of submission. (CASH OR
PERSONAL CHECKS CANNOT BE ACCEPTED - MAKE MONEY ORDER OR CERTIFIED
CHECK payable to HAUPPAUGE PUBLIC SCHOOLS). After a student has been admitted to the
program, NO REFUNDS WILL BE GRANTED.
It is most important that students and parents understand the attendance requirements that exist for this onesemester program. To successfully complete Driver Education, each student must meet the following
minimal time requirements, as prescribed by New York State and pass a written examination,
administered locally to receive their 5-hour certificate:
CLASSROOM INSTRUCTION
CAR (on-road) INSTRUCTION
CAR (observation)
24 Hours
6 Hours
18 Hours
When a student is absent from any session, including extracurricular activities and sports, it must be
made up within that month. It is the pupil's responsibility to find an opening in a session, a task that is often
difficult. If the session is not made up within the month, the pupil must attend an emergency make-up
session at the end of the course. This opportunity will be available to make up only a single car, or class
session. The student will be dropped from the class upon the third absence, and any absences that are not
made up will result in the student being dropped from the program with NO REFUND.
In accordance with New York State Education Department guidelines, NO CREDIT TOWARD
GRADUATION can be earned by pupils enrolled in a driver education program with a tuition fee.
I have read, understand, and agree to the terms of enrollment for the Hauppauge H.S. Drivers Ed Program
and give my permission for my child's enrollment.
______________________________
Parent Signature
________________________________
Student Signature
Class
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
MONDAYS
Feb 1
Feb 8
Feb 22
Feb 29
Mar 7
Mar 14
Mar 21
Mar 28
Apr 4
Apr 11
Apr 18
May 2
May 9
May 16
May23
June 6
TUESDAYS
Feb 2
Feb 9
Feb 23
Mar 1
Mar 8
Mar 15
Mar 22
Mar 29
Apr 5
Apr 12
Apr 19
May 3
May 10
May 17
May 24
May 31
Make up dates:
June 7 & 9
THURSDAYS
Feb 4
Feb 11
Feb 25
Mar 3
Mar 10
Mar 17
Mar 24
Mar 31
Apr 7
Apr 14
Apr 21
May 5
May 12
May 19
May 26
June 2