Application

Student Name: _________________________________________________

 

Parent Name:___________________________________________________

 

Birthday: _______________________________________________________    

 

Learners permit number(if applicable): ________________________________

 

Mailing Address: _________________________________________________

 

City, State, Zip Code: ______________________________________________

 

Student cell phone: _______________________________________________

 

Parent cell phone: ________________________________________________

 

Home Phone: ___________________________________________________

 

Name of Car Insurance: ___________________________________________

 

 

As a parent signing this form, I release Jackson Hole Driving Academy and other involved parties from any claims or responsibility for any accident or inury while my son/daughter is practicing driving as part of this program.

 

As a studen, signing this form, I agree to follow all rules and instructions from the Jackson Hole Driving Academy. I also release Jackson Hole Driving Academy and other involved parties from any claims or responsibility for any accident or inury while practicing driving as part of this program.

 

__________________________________________  / ______________

   

     Signature of Parent or Guardian                                     Date

 

 

 

__________________________________________  / ______________

   

     Signature of Student                                    Date