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Spring 2014 Letter

In: Business and Management

Submitted By kliu
Words 447
Pages 2
HORACE GREELEY HIGH SCHOOL DRIVER EDUCATION PROGRAM
APPLICATION/CONSENT SLIP
70 Roaring Brook Rd/Chappaqua, NY 10514 (914) 861-9421 chappedu@ccsd.ws

Today’s Date:________________
Student’s Name, Address, Date of Birth and Permit/License # MUST BE EXACTLY as on the permit/ license otherwise the DMV will NOT Convert Junior-to-Senior License Male ( ) Female ( )

__________________________________________________________ ___________________________
Last First Middle Date of Birth

__________________________________________________________ _____________ / _______________
Number Street Home Phone Student Cell Phone

__________________________________________________________ ___________________________
City State Zip Code E-Mail Address

PERMIT/LICENSE NUMBER: _____________________________ ________________________________ (Required by Feb. 7, 2014) Name of Full-Time High School
The program consists of 90 minutes of driving and 90 minutes of lecture class each week for 16 weeks. Driving Time: Please indicate your top 3 driving preference days by placing a 1, 2 & 3 in the boxes below. Next to the number, indicate the earliest time you can start driving. Please be aware that student registration priority and teacher availability may limit some choices.
Lecture Preference Wed. Sat. 2:55PM_____ 9:00AM_____

4:25PM_____ 10:30AM_____

5:55PM_____

Subject to enrollment and teacher availability. ( ) Mon ___________ ( ) Tue ___________ ( ) Wed ___________

( ) Thu ___________ ( ) Fri ___________ ( ) Sat ___________

Lecture Class: Please indicate your top 3 lecture preferences by placing 1, 2 & 3 in the Lecture Preference box on the right. PARENT/GUARDIAN INFORMATION AND CONSENT
I give my child permission to be enrolled in the aforementioned driver education program.

___________________________ ___________________________ ____________________
Parent/Guardian (Print Name) Parent/Guardian (Signature) Date

EMERGENCY CONTACT INFO: __________________________ ____________________ Name Phone
IMPORTANT INFORMATION
1) A permit is required by February 7, 2014. Fe
2) The spring program starts February 10th and will be conducted for 16 weeks.
3) Fee for the program is $515. Students who do not live in the Chappaqua Central School District must include an additional $50.00.
4) Please make the check payable to Chappaqua Board of Education and mail it with the completed application, signed by a parent or guardian, to the Chappaqua Continuing Ed Office/HGHS/70 Roaring Brook Rd., Chappaqua, NY 10514.
5) Payment is required with this application. Refunds will not be issued after Monday, February 24, 2014. Refunds issued before Monday, February 24, 2014 are subject to a $20.00 cancellation fee.
6) Students must complete all requirements by the end of the semester.
7) Course requirements and assignments will be provided at the mandatory 90-minute Orientation on Tuesday, February 4th at 3:00pm in K110.
8) Driving instruction is provided by PAS Auto School (914) 332-7700.
DO NOT WRITE BELOW THIS LINE. FOR OFFICE USE ONLY.

ASSIGNED DRIVING TIMES ___________ ______________ _______________ Day Time Teacher

ASSIGNED LECTURE TIMES ____________ ______________ _______________ Day Time Teacher

PAYMENT ______________ CHECK # ____________ DATE _______________

PR___ DA___ PU___ PA___

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