(TO BE FILLED OUT BY PARENT/GUARDIAN)
BELLOWS FREE ACADEMY DRIVER EDUCATION PROGRAM
STUDENT________________________________________________DOB____________AGE________
(Name as on permit)
PERMIT NUMBER_____________________DATE OF ISSUE_____________________
Parent email address (optional) __________________________________________
Home telephone # _____________________ Grade__________
1. Please circle below any of the conditions the student has:
Heart trouble Bloody nose Diabetes
Allergy to bee stings Learning disability Depression
Wears glasses/contacts Hearing difficulties Anxiety
2. Please state any information about your child’s health that you want us to know.
_____________________________________________________________________________________________
3. Does your child take any medications regularly? If yes, please state the name of the medication and the reason for taking it_______________________________________
4. Do you consider your child capable physically, mentally and emotionally to drive?_____________________
5. Has your child had any experience driving a farm tractor, ATV or lawn tractor? If yes, what and how much?________________________________
6. How many hours has your child been driving behind the wheel of a car/truck? _______
7. Has your child ever received help from the resource teacher, special educator, or
speech pathologist?_____________If yes, when________________________Is your
child currently receiving special services in school?_______If yes, What services and
from whom? _____________________________________________________________
