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APPLICATION FOR ADMISSION
STUDENT'S NAME (Legal)_____________________________________
DOB ____-____-____ AGE_____
ADDRESS____________________________________________________
CITY_________________________________________
ZIP__________
E-MAIL____________________________SCHOOL___________________
PHONE #______________________ PHONE #______________________
ALTERNATE CONTACT (in case of emergency) __________________
Phone#______________________Relationship___________________
SIGNATURE__________________________________________________
PARENT OR GUARDIAN IF STUDENT IS A MINOR------DATE
Enclose $195 DEPOSIT ___ or $395 FULL PAYMENT___ AAA Member $355.50____
Driving only (6 Hrs) $360 _____
{AAA discount does not apply}(Include copy of online driver education certificate of
completion) Any cancellation of a class before the starting
date will result in a non-refundable $50 filing fee. In the event that your child has started
the course, but is unable to finish, he or she may continue in the next session without additional fee. Otherwise, the full tuition fee is forfeited. It is also required that we notify the state of any students who do not successfully complete the driver education course or who withdraw for any reason, the driver education
permit will then be invalidated. Full payment is required on or before the first
day of class. Date_______________
and Time____________ of requested class
Location: __Terre Haute; __Brazil;
__Crawfordsville; __ClintonAAA
Motor Club Membership Number ________________________________
*SAMMERS DRIVING SCHOOL ALSO ACCEPTS VISA, MASTER CARD AND DISCOVER.
Name on the card (print)__________________________________
Card number_______________________________________________
Expiration date___________ Charge amount_________________
Cardholder signature______________________________________
Date____________________
Please
return this application with deposit or full payment to:
SAMMERS DRIVING SCHOOL, P.O. BOX 3361, TERRE HAUTE, IN 47803.
We will send or e-mail a confirmation that we have received your application.
A second letter will be mailed with
certification of enrollment to receive your permit 3 weeks before class begins.
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For Office Use Only
Received _____Confirmation _____CDE Form _____Contract ____
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