Behind The Wheel- Stafford Area **Zip Code 22554 Area or Must be willing to meet the instructor**

Students Name *

Email *

Address *

City/Town *

State/County *

Zip/Post Code *

Phone *

Age *

Students Date of Birth *

What School Does Student Attend * Select ... Stafford Senior High North Stafford High Brooke Point High Colonial Forge Mountain View James Monroe Riverbend Chancellor Courtland Spotsylvania Other No longer in school

Does student have their certificate of completion from Drivers Ed Classroom? * Yes
No

Has the student and parent attended the 90 minute parent/teen meeting? * Yes
No

Has student completed at least 45 hours of driving this includes 30 daytime hours and 15 nighttime hours? * Yes
No

Would student be able to meet the instructor or is pick up and drop off at home necessary? * Can Meet Instructor
Can NOT Meet Instructor

Does student have any activities that may interfere with scheduling during certain times? * Yes (if yes Please note in comment section)
No

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