DriveWise Student Intake Form

Course Start Date: ______________________________Course #:____________________________________

Student Name: _______________________________________________________________________________________________________

Birth Date: Month: _______________________Day: ______________________ Year: ________________________________________

Home Address: ______________________________________________________________________________________________________

City: _________________________________________________________________Postal Code:___________________________________

Alternate Address (work, school etc.): ____________________________________________________________________________

Student Cell #: ________________________________ Alternate /Parent Cell #: ________________________________________

Student Email: ______________________________________________________________________________________________________

Alternate (Parent) Email: __________________________________________________________________________________________

Licence #: ___________________________________________________________________________________________________________
Issue Date: Month: _________________________Day: _______________________Year: _____________________________________

Expiry Date: Month: ________________________Day: _______________________Year: _____________________________________

Earliest Exam Date: ______________________________________MM/DD/YYYY (Bottom right corner of your picture ID)

Are you eligible for high school credits? Yes  No 

Which high school do you attend_________________________________________________________________________________

• Do you have previous driving experience? Yes  No

• If yes, approximately how many hours ___________
• Will you get practise between our teaching lessons? Yes  No

If not, we have extra practise lessons available to assist with extra time on the road to help you achieve
your goal of being a safe, confident driver and road test ready. Practise in between lessons is highly
recommended! Please give us a call for more information.