City of Chattanooga

City of ChattanoogaDrivers Education Program

Winter 2013/14 Application for Enrollment*

*Thissigned application and the $50 enrollment fee must be received NO LATER THAN TWO (2) WEEKS prior to the beginning of the class. NO EXCEPTIONS

Student ______Gender: M____ F____

Address______Zip code ______

Date of Birth______Age_____Cell #______School______

Parent/Guardian______

Address______Zip code______

Home phone______Work______Cell______

E-mail______Fax______

Parent/Guardian______

Address______Zip code______

Home phone______Work______Cell______

E-mail______Fax______

Do you have any medical condition which would require special accommodation to insure that your classroom and/or behind the wheel instruction is effective? ______

If yes, please explain the nature of the accommodation required.______

______

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This city-sponsored program will provide basic defensive driver education. The instructor will furnish a car equipped with automatic transmission for use during in-car training and any materials necessary for classroom instruction. The course is presented with strict adherence to state regulatory requirements.
Student agrees to pay a $50 non-refundable fee upon enrollment. The fee and this completed application must be mailed to: City of Chattanooga, Traffic Engineering Division; 1250 Market Street, Suite 3030; Chattanooga, TN 37402. Only checks or money orders, made out to the City of Chattanooga, or cash will be accepted. The City will pay the $300 balance to the driving instructor upon successful completionof the course for qualified City residents only. All non-City residents are required to pay the full course fee of $419to the driving instructor.
In the event a check is returned from the bank for non-sufficient funds, the student and/or parent will be responsible for immediate repayment of the $50 in cash or money order only plus a $20 returnedcheck fee, also in cash or money order.
In the event the student fails to satisfactorily complete the course in its entirety, the balance due on the program fee will be the sole responsibility of the student and/or parent.
No make-up classes will be offered. If the student misses one day in a 4-day course, he/she must withdraw and re-enroll from the beginning in the next available class, pending space availability.
Student agrees to participate in 30 hours of classroom time, with an additional 6 hours of behind-the-wheel instruction which will be scheduled once classroom requirements are met. The 6 hours of behind-the-wheel instruction MUST be scheduled within 6 months of completing the classroom instruction.
It is the student’s responsibility to contact the instructor in the event of tardiness, illness or any other situation that may alter the scheduled driving lesson time. The instructor and student may schedule a make-up lesson at a time convenient for both.
In the event the student causes, participates in or encourages any disruptive or disrespectful behavior which results in an interruption in class instruction and/or a delay in covering required course material, he/she will be dismissed, and the balance of the course fee ($300) will becomethe sole responsibility of the student and/or parent(s)/guardian(s).

I, STUDENT’S NAME have read the above listed requirements for participation in the City of Chattanooga’s Drivers Education Program and agree to abide by these conditions.

Student______Date______

For students under the age of eighteen (18):

I/We, PARENT/GUARDIAN NAME(S) certify that the minor is a student in good standing and has no disciplinary or truancy issues.

Parent/Guardian______Date______

NOTE: A confirmation letter will be mailed to the student upon receipt of the completed application form and enrollment fee.

Direct any inquiries concerning the Drivers Education Program to:

Traffic Engineering Division

1250 Market St, Suite 3030

Chattanooga TN 37402 Office 423-643-5963, Fax 423-643-5951