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LOCATION 156 Everett Ave Newark, Ohio 43055 740-349-0955 (Near totem pole on Everett Ave corner of Front St)

The following is a work sheet, the kind of information we will need to complete our files.

BASIC INFORMATION – be prepared to answer the following on school forms.

STUDENT FULL NAME
DATE OF BIRTH
HOME ADDRESS 1
HOME ADDRESS 2
CITY, STATE, ZIP
PRIMARY NUMBER (HOME)
ALTERNATE NUMBER (CELL)
EMAIL ADDRESS (OPTIONAL)
EMERGENCY CONTACT #1 NAME
CONTACT #1 NUMBER ; RELATIONSHIP
EMERGENCY CONTACT #2 NAME
CONTACT #2 NUMBER : RELATIONSHIP
DOCTORS NAME
DOCTORS ADDRESS
DOCTORS PHONE NUMBER
NAME OF MEDICAL INSURANCE CARRIER
If beginner teen driver, do you have a permit	YES or NO = If yes, issue date:
If beginner teen driver, are you age 16+ ?	YES or NO = If NO, 16^th birthday:
If student is under age 18	We need parent/guardian information
PARENT OR GUARDIAN’S NAME
PARENT OR GUARDIANS WORK #

BEGINNER DRIVERS We will need to copy students permit before first drive. PLASTIC ID and VALIDATED PAPER

JUVENILLE DRIVER PROGRAM CURRENT PICTURE ID DRIVER LICENSE NUMBER Ticket or BMV or Court Documents

ADULT REMEDIAL CLASS CURRENT PICTURE ID DRIVERS LICENSE NUMBER Ticket or BMV or Court Documents

SEATING FOR CLASSES LIMITED - (walk in students accepted if seating is available )

PRE-REGISTRATION PREFERED – JUST CALL OR EMAIL THE OFFICE

DATE OF CLASS :___________________- TIME CLASS STARTS _____________________

CLASS LOCATION : NEWARK MAIN LOCATION OR HEATH BRANCH

PLEASE COME TO OFFICE TO COMPLETE FORMS BEFORE CLASS BEGINS.

REQUIRED SCHOOL FORMS NEED TO BE READ – SIGNED – QUESTIONS ANSWERED.

IF UNABALE TO COME TO OFFICE DURING BUSINESS HOURS, THEN AT THE VERY LEAST

ARRIVE 25 mins. to ½ HOUR BEFORE CLASSES BEGIN. DURING THESE LAST FEW MINUTES BEFORE CLASS BEGINS, WE WILL NOT HAVE MUCH TIME FOR INDIVIDUAL ATTENTION TO ANSWER QUESTION, PLEASE CALL OR STOP BY THE OFFICE IN ADVANCE WITH QUESTIONS.

ALL CLASSES BEGIN AT SCHEDULED TIME, Thank you LOLDS

THANK YOU from the Land of Legend Driving School, Staff and Management