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APPLICATION FOR ADMISSION
STUDENT'S NAME (Legal)_____________________________________
DOB ____-____-____ AGE_____ (at least 15 on or before the 1st day of class)
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 $175 DEPOSIT ___ or $375 FULL PAYMENT___ (AAA Member
$337.50____)
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
School
Attending: __Terre Haute; __Brazil; __Crawfordsville; __ Spencer AAA Motor Club Membership Number ________________________________
Name(s)of student you will
be carpooling with? __________________________
Driving preference
during the week or on the weekend? _________
*SAMMERS DRIVING SCHOOL ALSO ACCEPTS VISA AND MASTER CARD.
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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