EYE EXAM/SCREENING FORM. The results of the eye exam or screening taken on for (Date) are as follows: (Name of student)

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1 EYE EXAM/SCREENING FORM Please ask your doctor or school nurse to complete the form below and forward to our office. The eye exam or screening must be less than 1 year old. The results of the eye exam or screening taken on for (Date) are as follows: (Name of student) Corrective lens are needed for driving Corrective lens are not needed for driving Signature of Healthcare Professional Please contact me at if you have any questions or concerns. The fax number is

2 DRIVER EDUCATION PARENT PERMISSION FORM Student s Full Name (Please Print Neatly) First Middle Last Name must correspond to the name on the child s birth certificate Physical Address City/State/Zip Birth Date MM / DD / YY The above named child meets the eligibility requirements for the driver education course sponsored by the State Department f Education and has my consent to participate in the driver education course. The classroom phase consists of a minimum of 30 hours. Attendance is mandatory to meet state requirements. IF A STUDENT FAILS TO TURN IN A COMPLETED NOTEBOOK BY THE DUE DATE GIVEN BY THE INSTRUCTOR, HE/SHE WILL AUTOMATICALLY FAIL. Road work consists of seven hours of driving and seven hours of observation. We will attempt to be flexible and accommodate the needs of families when developing driving schedules. However, there may be times when we are not able to meet everyone s needs. Please be prepared to adjust family schedules in order to complete driving practice within a reasonable timeframe. A student must be passing the class work in order to be scheduled for road work. Students must pass both class work and road work with at least a grade of 70% in order to pass the driver education class. The following rules will be in effect at all times. Follow all safety rules in the car and classroom. Follow directions the first time they are given. Be in assigned seat, ready to work, when class time begins. Complete all assignments fully and on time. Raise hand and wait to be recognized before speaking. Keep hands, feet and other objects to yourself. Any discipline problems will result in the student being disenrolled from the driver education class. 2

3 PARENTS - PLEASE CAREFULLY READ AND INITIAL EACH ITEM BELOW: I understand that a driver s license issued to anyone under 18 years of age is automatically a restricted learner s permit for the first year. I understand that during the first six months the student driver must be supervised while driving at all times. I understand that during the second six months the student driver may drive unsupervised during the day but must be supervised at night after 10:00 p.m. and prior to 6:00 a.m.(unless traveling directly to or from a school event or work; at this time no passengers are permitted in the car.) I understand that as the parent/guardian, I am entitled t withdraw my permission for my son/daughter to drive between the ages of 16-18, for any reason and that I can simply return my son s/daughter s driver s license to the DMV. Are there any medical/physical/mental conditions that require special attention in driver education? Yes No Please explain: Please be aware that if the blue certificate awarded at the completion of driver education is lost, it is necessary for you to write the Department d Education, in Dover, to request a duplicate this could take several weeks. I have read and agree to abide by the regulations as set forth above and further agree to follow all other verbal and written instructions given in the classroom and car. Student Signature Date Parent/Guardian Signature Date 3

4 SUSSEX TECH ADULT DIVISION DRIVER EDUCATION STUDENT CONTRACT As a Sussex Tech Driver Education student, I will sign this contract, after reading in full. My signature indicates that I understand and agreed to the terms of this contract for the driver education program. 1. Attendance is required in order to pass this course. I understand and will abide by the attendance policy in the Student Handbook. 2. Smoking is prohibited on school property. I will not smoke on school property, including along the roadway in front of the school. 3. I will not leave the class except at break time. I will inform the instructor of any emergency that causes me to leave the class. 4. I agree to abide by the emergency procedures for evacuation and/or remaining in the building. 5. I understand that habitual lateness to class and or early departure from class could result in failure of the class. 6. I understand that I am responsible for my own transportation to and from school. 7. I understand that I have the responsibility for following the established dress code. 8. I understand and will comply with the alcohol and controlled substance, weapons and conduct policies included in the Student Handbook. 9. I understand that cheating will result in disenrollment from the program. 10. I will follow all rules and policies of the Sussex Tech Adult Division and the Sussex Technical School District. 11. I will behave as an adult and act accordingly, accepting responsibility for my educational effort. 12. I will not interfere with another student s right to learn. 13. I agree to pay all course fees or payments as required. 14. I grant permission to Sussex Tech Adult Division to broadcast my likeness in face and figure by means of television, motion picture film, videotape recording, internet websites, or still photography at the time and dates to be determined by Sussex Tech Adult Division. I, the undersigned, have read, understand and agree to abide by the above regulations. Printed Student Name Student Signature Parent Signature (For students under 18 years of age.) Date 4

5 Academic Eligibility This is to verify that I understand there are new laws, effective July 1, 2000, which require anyone under the age of 18 to meet specific academic requirements in order to obtain a Delaware Driver s License. I understand that successfully passing a driver education class at Sussex Tech Adult Education, does not guarantee that I will qualify for a Delaware Driver s License. I understand that in order to receive a Certificate of Completion for the Driver Education class, I must meet all requirements of the course and I must submit proof that during my latest marking period of school I was passing at least five full credit classes (two of which must be in math, science, language arts or history). I understand that if I have completed the program in the 4th marking period, year-end/final grades will be used to determine eligibility. Or, if going to Groves High School or GED preparation classes, I must provide proof that I have had good attendance for at least 3 months and any other criteria as required by the principal. Student Signature & Date Parent/Guardian Signature & Date 5

6 BLUE CERTIFICATE SAMPLE PLEASE NOTE: Your name must match your Social Security Card and your Birth Certificate. Your address must match the parent or sponsor s Driver s License address that will be taking you to pick up your license. Please print your name and address as you would like for it to appear on your blue certificate. Date of Birth, 20 This is to certify that First Middle Last Address City State Zip This is how your blue certificate will appear. Please return at orientation. 6

7 Academic Eligibility Information For Home Schooled Students In accordance with Delaware Code, Titled 14, Chapter 27, 2703 A, is enrolled in a non-public home school in Delaware. To receive a Driver Education Certificate, i.e. blue slip, this individual must: Register with the Department of Education, home school registration # Successfully complete a driver education course Earn passing grades in 5 credits by the end of the driving education course with at least 2 of the credits in English, Mathematics, Science, or Social Studies Signature Of Parent Or Legal Guardian Date

8 SUSSEX TECH ADULT DIVISION DRIVERS ED PROGRAM PERMISSION SLIP Date: Name of Student: Please check one of the following: I grant permission for my child to drive alone with his/her instructor if my child s driving partner misses his/her driving appointment. I do not grant permission for my child to drive alone with his/her instructor for any reason. (Parent s Signature) Y:driver ed everyone/permissionslipfor singledrivers

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