* "Student's Name" or " Nick Name " in quotes

The Name that the student wants to be called in class

CLASS NUMBER

Class Start Date

* First Name Middle Last Name

INSTRUCTOR NAME

* Street Address Full street address include Road, Lane, Terrace, Blvd…

* Town & Zip Code

* ( Area Code ) PHONE NUMBER

* BIRTHDATE, INCLUDE Month / Day / Year

* Subdivision Name

(Only if the student lives in a subdivision )

* NEAR THE INTERSECTION OF:

_____________________ and _________________

* NEAR THE ________________________

STUDENTS CAN DRAW A MAP

TO GET TO THEIR HOUSE FROM THEIR

NEIGHBORHOOD, FROM THEIR INTERSECTION

FROM THE NEAREST STOP SIGN, OR SIGNAL LIGHT…

BOTTOM RIGHT CORNER OF PAPER

* Driving Situation

When the student is going to get their permit,

who the student wants to drive with, when, where…

pick up places,

* Home situation

Who does the student live with, what are the other pick

up addresses, extra phone lines, pager number, cell #…

* Work Situation

Does the student work? Babysit ? Work for parents?

Where ? When ? Address ? Phone ?

Will student need to be picked up at work ?

* School

BOTTOM LEFT CORNER

What School, What Year, Home Schooled ? Ged ?

Tips to get to the students house

* Hobbies / Interests

Color of house, garage, shutters…

Landscape tips, trees, bushes, fence….

* Clubs, Sports, Activities ?

Driveway entrance tips, mailbox color, long driveway….

Watch out for dog, neighbor, little children, cats….

* E-Mail Address