(last) (first) (middle)
(NAME SHOULD BE EXACTLY AS IT APPEARS ON BIRTH CERTIFICATE)
ADDRESS: ____________________________________________ ZIP __________
PHONE ____________ DATE OF BIRTH _________________ AGE _______
(month, day, year)
SR. JR. SOPH. FR. (circle present grade)
My son ______________________________ has my permission to participate in the Driver Education Program sponsored by Mount St. Joseph High School. He is 15 ½ years of age or older.
I understand that, if accepted, he:
PARENT’S SIGNATURE: ______________________________ DATE: _____________
NOTE: The fee of $395.00 must be paid at the time of registration. Payment must be made by check or money order payable to: Mount Saint Joseph High School. Refunds cannot be made after the first regularly scheduled classroom session.
This application must be filled out accurately and completely.