Alert Driver Training of Vinton

Application for Instruction for Students Under 19

Behind-the-Wheel 14-hours of in car instruction only
Do you have classroom completion certificate ? yes no
Please include certificate with application if yes. / Classroom Only
36 hours of in class instruction
Start Date of Class: / Package
Classroom/Behind the Wheel
Start Date of Class:

Student Name:______D.O.B.______

LastFirst Middle Name

Home Address:______Home Phone:______

Street

______Student Work Phone:______

City State Zip

High School:______Grade:______

Learner’s

Permit: Yes No ______Issue Date:______

Permit No. (required if issued) required

Parents/Guardian Name:______DaytimePhone______

please printrequired
Answer following questions by marking Yes or No
  1. Has student experienced a physical, mental or visual illness, injury, or condition that may affect the student’s ability to operate a motor vehicle during instruction, routine, or heavy traffic conditions? Yes No
  1. Has student experienced a blackout, seizure, loss of consciousness, or syncopy?Yes No
  1. Does student take any medication/drug prescribed by a physician or otherwise on a regular

basis that would impair his/her ability to drive?Yes No

  1. Is the student’s privilege to drive or eligibility to obtain a Virginia instructional permit

or Driver’s License prohibited, suspended or revoked by any court or the Department of

Motor Vehicles?Yes No

5. Has student experienced any reading or learning disability?Yes No

  1. Has student experienced signs of anxiety or is overly fearful of driving or taking this course?

Or, does student have any other special needs? Note: Making the instructor aware of anxiety,

fear, or special needs will enable instructor to work more effectively with the student.Yes No

If yes, please list:______

______

7. Is student working on the 45 hours of practice driving with 15 hours being after sunset?Yes No

If yes, how many hours of practice time have been logged?______

Over

Driving School Rules

  1. NOISE: An atmosphere conductive to learning must be maintained for ALL students. Loud talking among students, noise, or disruptions to the instructor or other students are not allowed. Any objects of distraction or destruction may be confiscated and held until end of class. To prevent having personal objects taken, do not bring them to class (i.e. lighters, radios, etc.)
  1. DAMAGE & TRASH: There is to be no damage (including writing) to the equipment, tables, chairs, desks, or walls. All drink cans and snack wrappers are to be disposed of in the proper places (trash can).
  1. PERSONAL ITEMS: The school will not be held responsible for any personal items lost or left in our classroom.
  1. DRUGS/ALCOHOL: If a student under the age of 18 is suspected of using drugs or alcohol before, during or after class, the police will be called.
  1. SMOKING: It is against the law for anyone under 18 years of age to use or have in their possession tobacco products such as cigarettes, chewing tobacco, snuff, etc. If a student under 18 years of age is found to possess such items, the proper authorities will be notified.
  1. If anyone over the age of 18 years is found giving or distributing tobacco products, drugs or alcohol to minors, the police will be notified.

7.Under no circumstances will a student be allowed to drive on the school’s property while using a learner’s permit unless there is an authorized adult with him/her in the vehicle.

8.We STRONGLY discourage parents/guardians from allowing their children to drive anywhere or anytime without a licensed authorized adult in the vehicle with them.

9.The student/parent/legal guardian fully understand that any intentional dangerous acts in the nature of horseplay, pranks, class disruptions, willful misconduct, or willful damage to school property are

are grounds for immediately expulsion without refund. Student/parent/legal guardian understand that should any damage arise to school property, they will be held libel for cost of replacement.

I certify that all information given in this application is true to the best of my knowledge , and I agree to abide by all Driving School Rules listed above.

Student Signature: ______Date:______

Parent/Legal Guardian

Signature:______DATE:______

(Revised 02/09)

BEHIND-THE-WHEEL STUDENTS, IF YOU HAVE YOUR “GREEN CARD”, IT MUST BE INCLUDED WITH APPLICATION.

Page 2

Alert Driver Training of Vinton

2104 Hardy Road, Vinton, Virginia 24179(540) 890-0347Fax (540) 890-8877

Instructional Agreement

Alert Driver Training of Vinton was founded to teach the latest defensive driving techniques and to enhance driver awareness of risks faced while driving. We are dedicated to a quality educational program and making Virginia a safer place to live. In keeping with our educational principles, Alert Driver Training of Vinton, assures the following:

The course curriculum is presented by instructors licensed by the VirginiaDepartment of Motor Vehicles.

The Driver Education Program is State approved and meets or exceeds standards set by the VirginiaDepartment of Education and the VirginiaDepartment of Motor Vehicles.

Textbooks, course materials, a dual control vehicle with a brake pedal on the right-hand side for the instructor’s use, and is equipped with restraint systems, extra rear view mirrors, and rooftop and rear signs are provided.

This Instruction Agreement is for practice instruction only.

Client Agreement

The client certifies that all information contained in the application for instruction is true and accurate to the best of his/her knowledge, and that the application is a request for the client to enroll in the In-Car Driver Training Program.

The client fully understands and agrees that attending the course of instruction does not constitute successful completion nor does it guarantee any client a Virginia State Driver’s License. All academic standards and licensing requirements must be met as set by the Virginia Department of Education and the Virginia Department of Motor Vehicles to successfully complete the course and/or obtain a Virginia Driver’s License.

The client agrees that in the event of a medical emergency, any instructor or agents of Alert Driver Training of Vinton may authorize medical treatment by a proper medical facility, hospital, physician, etc. if the client is physically unable to authorize medical treatment for him/herself if over eighteen (18) years of age.

The client fully understands that any intentional dangerous act in the nature of horseplay, prank, willful misconduct or class disruptions are grounds for immediate expulsion without refund.

The client fully understands and agrees that no client is to be in a driver training car with the motor running or with the keys in the ignition switch unless accompanied by a Certified Alert Driver Training of Vinton instructor.

The client fully understands and agrees that successful completion of the Alert Driver Training of Vinton Behind-the-Wheel course does not imply that the client is an accomplished driver. No one can be considereda skilled driver until he/she has driven for several years.

I have read and fully understand all parts of this agreement.

Client:______Date:______

Address:______

Parent/Guardian:______Date:______

Relationship to client:______

Address if different than client:______

Alert Driver Training of Vinton Representative:

______Date:______

Under no circumstances will a student be allowed to drive on the school’s property while using a learner’s permit unless there is an authorized adult with him/her in the vehicle.We STRONGLY discourage clients to drive anywhere or anytime without a licensed authorized adult in the vehicle with them.

Terms of Agreement

The client/parent/legal guardian agrees to pay all the costs of instruction prior to the beginning of the course or may choose a payment plan as follows. (Note: The fees set herein are subject to change without notice.)

This contract constitutes the entire agreement between the student/parent/legal guardian and no verbal representations, assurance or promises not contained herein shall bind the school or the student/parent/legal guardian.

$30.00 application fee is non-refundable in the event a request is made for reimbursement unless

Alert Driver Training can perform its contract in a reasonable time period.

$30.00 service fee for all returned checks.

The fees for the course(s) are as follows:

Classroom / Behind-the-Wheel / Package
Due with application / $100.00 / $100.00 / $100.00
Due at first class session / $100.00 / $155.00
Balance due by 1st driving session / $210.00 / $155.00
TOTAL COST / $200.00 / $310.00 / $410.00

Additional tutoring is available if needed. Please see an instructor for fees. Please contact AlertDriverTraining School if you have any questions at 540-890-0347.

(The DMV is committed to promoting transportation safety through the certification of quality driver training programs. If you have any comments or concerns about this course, call the DMV toll free at 1-877-885-5790.)

Please complete application and return Page 1 and Page 2 to:

Alert Driver Training of Vinton

P. O. Box 1176

Vinton, VA 24179

Page 3 – Customer Copy (Please retain for your records.)

Page 3 CUSTOMER COPY

Alert Driver Training of Vinton

2104 Hardy Road, Vinton, Virginia 24179(540) 890-0347Fax (540) 890-8877

Instructional Agreement

Alert Driver Training of Vinton was founded to teach the latest defensive driving techniques and to enhance driver awareness of risks faced while driving. We are dedicated to a quality educational program and making Virginia a safer place to live. In keeping with our educational principles, Alert Driver Training of Vinton, assures the following:

The course curriculum is presented by instructors licensed by the VirginiaDepartment of Motor Vehicles.

The Driver Education Program is State approved and meets or exceeds standards set by the VirginiaDepartment of Education and the VirginiaDepartment of Motor Vehicles.

Textbooks, course materials, a dual control vehicle with a brake pedal on the right-hand side for the instructor’s use, and is equipped with restraint systems, extra rear view mirrors, and rooftop and rear signs are provided.

This Instruction Agreement is for practice instruction only.

Client Agreement

The client certifies that all information contained in the application for instruction is true and accurate to the best of his/her knowledge, and that the application is a request for the client to enroll in the In-Car Driver Training Program.

The client fully understands and agrees that attending the course of instruction does not constitute successful completion nor does it guarantee any client a Virginia State Driver’s License. All academic standards and licensing requirements must be met as set by the Virginia Department of Education and the Virginia Department of Motor Vehicles to successfully complete the course and/or obtain a Virginia Driver’s License.

The client agrees that in the event of a medical emergency, any instructor or agents of Alert Driver Training of Vinton may authorize medical treatment by a proper medical facility, hospital, physician, etc. if the client is physically unable to authorize medical treatment for him/herself if over eighteen (18) years of age.

The client fully understands that any intentional dangerous act in the nature of horseplay, prank, willful misconduct or class disruptions are grounds for immediate expulsion without refund.

The client fully understands and agrees that no client is to be in a driver training car with the motor running or with the keys in the ignition switch unless accompanied by a Certified Alert Driver Training of Vinton instructor.

The client fully understands and agrees that successful completion of the Alert Driver Training of Vinton Behind-the-Wheel course does not imply that the client is an accomplished driver. No one can be considereda skilled driver until he/she has driven for several years.

I have read and fully understand all parts of this agreement.

Client:______Date:______

Address:______

Parent/Guardian:______Date:______

Relationship to client:______

Address if different than client:______

Alert Driver Training of Vinton Representative:

______Date:______

Under no circumstances will a student be allowed to drive on the school’s property while using a learner’s permit unless there is an authorized adult with him/her in the vehicle.We STRONGLY discourage clients to drive anywhere or anytime without a licensed authorized adult in the vehicle with them.

Terms of Agreement

The client/parent/legal guardian agrees to pay all the costs of instruction prior to the beginning of the course or may choose a payment plan as follows. (Note: The fees set herein are subject to change without notice.)

This contract constitutes the entire agreement between the student/parent/legal guardian and no verbal representations, assurance or promises not contained herein shall bind the school or the student/parent/legal guardian.

$30.00 application fee is non-refundable in the event a request is made for reimbursement unless

Alert Driver Training can perform its contract in a reasonable time period.

$30.00 service fee for all returned checks.

The fees for the course(s) are as follows:

Classroom / Behind-the-Wheel / Package
Due with application / $100.00 / $100.00 / $100.00
Due at first class session / $100.00 / $155.00
Balance due by 1st driving session / $210.00 / $155.00
TOTAL COST / $200.00 / $310.00 / $410.00

Additional tutoring is available if needed. Please see an instructor for fees. Please contact AlertDriverTraining School if you have any questions at 540-890-0347.

(The DMV is committed to promoting transportation safety through the certification of quality driver training programs. If you have any comments or concerns about this course, call the DMV toll free at 1-877-885-5790.)

Please complete application and return Page 1 and Page 2 to:

Alert Driver Training of Vinton

P. O. Box 1176

Vinton, VA 24179

Page 3 – Customer Copy (Please retain for your records.)