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Does the student have any disabilities? If so, please explain.

Does the student qualify for Free and Reduced Lunch program? Y / N

Please deliver, fax or mail the registration form, $50 deposit and a copy of driving permit to: Lake Chevrolet Drive Wise | 3005 Willow Creek Court | Clear Lake, IA 50428. Please call 641.357.2612 with any questions. Credit Cards Accepted!

Card #________________________________________________ Expiration Date ______/_____/20___

*PLEASE NOTE: The total cost of $300 (except Hampton Classroom is $325) includes the $50 deposit due at the time of registration. Should a parent and/or student decide to cancel their registration from a class, all money paid will be refunded to them excluding the $50 deposit. If payment had been made for the deposit only upon cancellation of class, no reimbursement will be issued.

**I understand that it is my responsibility to notify Lake Chevrolet Drive Wise program if my students permit has been suspended during the durations of their class time.

Parent/Guardian signature

For more information call or email: 
Becky Rother, Program Coordinator   (641) 430-2835