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14 Hour Adult Class 5/23/2020
Drive Dat Academy would like to make your experience in our driving school first class. Please remember to go to the Office of Motor Vehicles to obtain the Temporary Instruction Permit. Also fill out the information below so we can prepare the documents with your information in order to save you the time from filling out the forms. Drive Dat Academy would like to thank you for choosing us for your driving education specialist. We will see you Saturday 5/23/2020. Remember Registration begins at 8:30 AM. Please make sure you have this form filled out by 5:00 pm Thursday 5/21/2020.
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Middle Name
*
Your answer
Last Name
*
Your answer
Home Adress
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age of Student
*
Your answer
Sex
*
Male
Female
Eye Color
*
Choose
Brown
Hazel
Blue
Green
Silver
Amber
Height in Feet
*
Choose
4
5
6
7
Inches
*
Choose
0
1
2
3
4
5
6
7
8
9
10
11
Students Weight in Pounds
*
Your answer
Hair Color
*
Choose
Black
Brown
Blonde
White
Red
Does the student wear glasses or contacts
*
Yes
No
Home Phone Number
*
Your answer
Work Phone Number
Your answer
Students Cell Phone Number
*
Your answer
1. Does the student have any medical conditions that would pose a concern with the student’s behind-the-wheel instruction (epilepsy, asthma, color blindness, hearing loss, etc.)?
*
Yes
No
2. Does the student have any mental or physical impairment which could affect his/her ability to drive a motor vehicle safely?
*
Yes
No
3. Has the student experienced unconsciousness other than normal sleep?
*
Yes
No
4. Is the student’s visual acuity at least 20/40 corrected?
*
Yes
No
5. Does the student require any special accommodations to participate in this course (i.e., oral tests, interpreter, seating arrangements, adaptive equipment)?
*
Yes
No
Describe locations where you have driving experience. Check the appropriate box(es)
*
None
Subdivision
Parking Lots
Rural Roads
In Town
Highway
Interstate
Required
What type of Identification will you provide the day of class.
Choose
Passport
Louisiana Identification Card
USA Residence Card
Identification Card of Another State
USA Work Permit
Other Type will be presented
How did you hear about us?
*
Your answer
A copy of your responses will be emailed to the address you provided.
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