STUDENT INFORMATION (Turn your printer on, click "File" and "Print", or just press Ctrl P.)

Course Start Date___________ Course Location___________________ Is student taking course Online? _____
Last Name ___________________ First _______________ Middle ini. ____ Home ph.:______________
Address ______________________________ City ______________ State ______ Zip ______________
Age ______ D.O.B.____________ Email _________________________ Student Cell # _________________
Parent/Guardian ________________________ Address _____________________ Phone _______________
Emergency Contact: ____________________Relationship___________________ Phone _______________
High School you are attending (Spell it out):____________________________________________

• Student agrees to pay in full, cost of classroom and driving instruction prior to last day of classroom instruction.
• Student agrees to be under the supervision of Hirons Driving Academy, during classroom and driving instruction.
• Student agrees to obey all rules, guidelines, and laws required by the school and the State of Indiana, and understands
  that failure to abide by the rules, guidelines and laws may result in the termination of training.
• Student acknowledges and agrees to the forfeiture of all money paid to the school in the event of instructional termination due fault of student, and/or failure to complete course within three months of Start Date.
• Student agrees to pay a fee of thirty dollars ($30.00) for any scheduled Behind-the-Wheel instruction missed without 24 hour prior verbal approval of the instructor.
• The student agrees and understands that there is no guarantee, expressed or implied, that the student will pass the state license examination upon completion of any course offered by the Hirons Driving Academy.
• The student agrees to conduct himself/herself in a mature manner and not be a distraction to any other student
• Student understands that Classroom Instruction and Behind-The-Wheel training must be completed within 120 days of enrollment date. Failure to complete course within time frame shall result in an incomplete grade and may result in the forfeiture of Permit and all monies paid to the school, unless an extension is granted.
• The student agrees to compensate the school for any personal property damaged by the student, and understands that all materials furnished by the school is the property of Hirons Driving Academy.
• It is understood that foul language, and/or disruptive behavior will not be tolerated during class, while behind the wheel, and/or within the premises of the school.
• Provide for prompt pick-up at end of classroom & driving sessions.
• Be on time for all instruction, and never come to any instruction after the consumption of alcohol or illegal substance.
• Student brings to class, a 3-ring binder with paper, and 2 pencils each day.
• Student agrees to complete 8 hours of driving practice with parent or guardian between each HDA driving lesson.
• There is a $35.00 fee for a returned check.

Parent and Student Agreement and Signatures

I hereby request and grant permission for my child, ____________________, to enroll in the state approved Driver's Education Course offered by Hirons Driving Academy, also referred to as HDA. I understand that the course consists of six hours of behind-the-wheel instuction, and thirty hours of classroom instruction. I further understand and agree that he/she will be under the supervision of HDA, and pledge my full support.

Student Signature _______________________ Parent: _______________________ Date: ______________