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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 #________________________________________________ CVC Code _________ Expiration Date ______/______  Amount $_____________

*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. All correspondence with student will also go to the parent.

**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    drivewisebecky@gmail.com
 

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