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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.
----------------------------------------------------------- For Office Use Only Received _____Confirmation
_____CDE Form _____Contract ____
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