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