Summer School Driver Education Non-Credit Program Registration Form

Summer School Driver Education Non-Credit Program Registration Form

***There must be no blanks in this document

Name:______School ID # ______

Birthdate ______/______/______School Attending ______

Parent/Guardian Name(s) ______

Address ______City ______Zip ______

Parent Contact Phone Cell ______Alternate Phone #______

Email Address: ______must reply with confirmation w/in 24 hrs

Student Phone(if applicable) ______

Emergency Contact Person if unavailable ______phone ______

Parent/Guardian: Please Initial each statement indicating that you have read, understand and agree to the terms of participation for the summer driver education program:

______I understand this is not a credited course and is an abbreviated summer program, and I want my child to participate even though they will not receive any credit towards graduation.

______I understand this course may not provide insurance credit and that anypremium reduction is at the discretion of my insurance company and that I want my child to participate regardless of this fact.

______I understand this is a commitment of 10 days for both my child and me, that if my child misses 2 days, at any point during the class, their spot will be forfeited.

______I understand my child needs transportation to and from location(BCH-tentatively). Students should arrive 5 minutes early and parents should be on time for pick up. Teachers will not be responsible for transporting or waiting at site for child to be picked up.

______I understand there will be no food/beverage services available; I will provide a snack and water bottle for my child to take with them as needed.

______I will notify IMMEDIATELY, through BOTH EMAIL and PHONE MESSAGE, if my child will not be participating in summer program and will reply within 24 hours of my confirmation/reminder email to confirm participation or release my child’s spot week of May 26th, 2014.

Signature ______Print name ______Date ______

Signature ______Print Name ______Date ______

Selections: CHOOSE 1 selection only

Complete Info Below Again

Name: ______School ID # ______

Birthdate ______/______/______School ______

Parent/Guardian Name(s) ______

Address ______City ______Zip ______

Parent Contact Phone Cell ______Alternate Phone #______

Email Address: ______must reply with confirmation w/in 24 hrs

DISTRICT USE ONLY BELOW- PARENTS DO NOT WRITE BELOW OR REGISTRATION WILL BE VOIDED

DISTRICT OFFICIAL PLEASE CHECK OFF AS COLLECTED AND EXPLAINED

Received legible and accurate copy of Driver Permit with Date of March 5th2014 or before/prior.

Received Completed registration Form.

Reminded Parent they must be present during entire Meeting and Present if called in Lottery.

Completed Ticket for Lottery Entry student name and parent name on ticket.

Placed in AM Bowl or PM Bowl as indicated above

SELECTED Not Selected

IF SELECTED PARENT RECIEVES

Program Information Sheet

Parent and Teen Handbook

MISC…

Please separate AM session in Alphabetical Order and PM session separately in alphabetical order

Please keep 10 alternates in order of being drawn for AM session and 10 alternates in order they were drawn for PM session