Boost Program Enrollment Form Boost Enrollment Form Step 1 of 4 25% Parent / Guardian InformationPrimary Guardian Role*- Please Select from List -MotherFatherStep-MotherStep-FatherGrandmotherGrandfatherAuntUncleOtherPrimary Guardian Name* First Last Email* Phone*Address* Street Address Address Line 2 City State Zip Is there a secondary contact?* Yes No Secondary Guardian Role*- Please Select from List -MotherFatherStep-MotherStep-FatherGrandmotherGrandfatherAuntUncleOtherSecondary Contact Name* First Last Secondary Contact Email* Secondary Contact Phone* Student InfoStudent Name* First Last Student Date of Birth* Month Day Year Student Gender* Male Female Student School* Grade Level* Student Driving InformationCurrent License or Driving Status*- Select Driving Status -No PermitPermitLicenseSuspended LicenseOtherDate License was issued* Month Day Year Number of Est. Hours Driving*Has student attending another driving school?* Yes No Name of Driving School Attended* Has student ever driven on the freeway or highway?* Yes No Has student recieved any tickets or been involved in a collision?* Yes No Please explain ticket or collisionPlease check the area of concentration you are seeking for the boost training* Red Light Running and Intersections Speeding Driving Spacing and Distance Management Distracted Driver Are you interested in an on-road evaluation of your student’s driving skills?* Yes No What is your reason or objective in placing your student in driver training?* Student MedicalDoes the student need vision correction?* Yes No Vision Correction Used Glasses Contacts Both Does your student live with medical, emotional, behavioral issues or have a specific diagnosis?* Yes No Please explain and include diagnosis and any co-morbidities*Has the student or is the student currently taking any medication and/or therapies?* Yes No Please explain medications or therapiesAre there any physical or cognitive challenges?* Yes No Please explain physical or cognitive challengesDoes the student use any implements (walkers, canes, etc.) hearing aids?* Yes No Please explain implementsHas the student had any recent surgeries including but not limited to brain surgery, eye surgery, or any medical treatment that has impacted movement, tracking, memory, or judgment?* Yes No Any other issues or concerns we should be made aware of that could impact the student's learning or comfort level?List any concerns you or the student has related to driver training
