JONES DRIVING SCHOOL

Subtitle

Medical Form

Medical Form      Date____________

Jones Driving School II

Student Name__________________________D.O.B.___________Home Phone_______________

Address____________________________________________________City____________________Zip_____________County_________________

P.O.Box#____________Parent/Custodian______________________________

Follow up letter will be sent to this person, if follow up letter is to be sent to different address other than students list address here

__________________________________________________________________________________

Doctor________________________________Phone_______________________________________

Dentist________________________________Phone______________________________________

Medical Specialist_________________________Phone______________________________________

Local Hospital____________________________Phone______________________________________

Ambulance______________________________Phone________________________________________

Please list any information concerning the child's medical history, including allergies, medications being taken, and any physical impairment.  

_____________________________________________________________________________________

_____________________________________________________________________________________

Telephone Numbers of authorized persons to contact if your child is ill or injured.  Parents/Relatives/Other: (please list relationship to child)

First Contact_______________________________________Phone______________________

Second Contact____________________________________Phone______________________

Third Contact______________________________________Phone______________________

Emergency Medical Authorization

______Yes, I authorize consent for emergency medical treatment                                

______No, I DO NOT authorize consent for emergency medical treatment                        

 

Signature of Parent or Guardian_____________________________________________


Jones Driving School II Contract

JONES DRIVING SCHOOL II CONTRACT

639 Wagner Ave.  Suite A              (937)548-9529

Greenville, Oh 45331

(please print)

Student's Name___________________________________________________________D.O.B.___________________

Address__________________________________________________________City___________________Zip________

Phone Number________________________ Permit/Lic. Number____________________Issue Date___________

The following guidelines are required by the Ohio Administrative Code and driver training schools are licensed by the Department of Public Safety through the Ohio Driving Training Program 1970 Broad Street, Columbus, Ohio 43223.  Jones Driving School II will carry out these guidelines.  

  •  Twenty-four hours of classroom instruction &eight hours of behind-the-wheel instruction based on the "Ohio Driver Training Curriculum" will be given by a licensed instructor.
  • Jones Driving School II in no way guarantees a class D operator license will be issued with the completion of this training.     
  • Three Hundred twenty dollars($320) payable to Jones Driving School by start of classroom time or $160.00 paid by classroom time, with the balance paid before the driving part of the training can be started. Or Three-hundred and twenty dollars ($320) for students that have taken on-line drivers training. 
  •  Certificate can be withheld till balance has cleared the bank.  There will be a (10.00) charge to replace lost Certificates.
  • A twenty-five dollar ($25) charge will be charged if student wishes to use the Jones Driving School II vehicle at the Greenville examination,  which is due on the day of the driving examination. A 24 hour notification of testing date is required. 
  • If student is unavailable or unable to drive at time of pickup or comes without their permit without an advance notice of 24hrs. to the instructor a twenty-five ($25) fee will be added.  
  • Jones Driving School II reserves the right to cancel this agreement at any time, should a student's conduct indicate a lack of responsibility deemed necessary by the driving school to safely operate a motor vehicle.  Destruction of property, or the possession, distribution, or use of any tobacco product, alcohol, or drug abuse is strictly prohibited. Jones Driving School II has the right to keep all payments if contract is cancelled for any reason.
  • Your signature below attests to the fact that you have read, understand, and agree to the terms of this agreement. 

DATE OF FIRST CLASSROOM INSTRUCTION___________________________________________________

All training & fees must be completed within six months from the first classroom date.

STUDENT SIGNATURE_____________________________________________________DATE_______________

PARENT OR

LEGAL GUARDIAN SIGNATURE____________________________________________DATE_________________

 JONES DRIVING SCHOOL II OFFICIAL________________________________________DATE________________


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