Road to Success

For more information or questions, please contact:

740.283.3347

roadtosuccess@jcesc.org
Road to Success

BEHIND THE WHEEL TRAINING

AGREEMENT
Student Name:*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
Date
Phone Number (Student Cell):*
Please enter a valid phone number.
Phone Number (Parent Cell):*
Please enter a valid phone number.
Phone Number (Home):
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Permit #/ DL # (example; two letters and six numbers; TL55796):*
Permit Date:*

MonthDayYear
Date
Please upload a copy of the Student Drivers Permit:*

Cancelof
High School:*
Jefferson County ESC Drivers Training, hereinafter referred to as “The Driving School” agrees to provide applicant, hereinafter referred to as “Student”, 8 hours of behind-the-wheel training based on the Ohio Driver Training Curriculum. The student will complete the 24 of classroom with an Ohio approved online provider prior to beginning the behind-the-wheel training. The student MUST provide the original certificate of completion from an approved online driver education program to begin the eight hours of behind-the-wheel training.*

I have read and understand the above statement.
State of Ohio regulations require all training be made available within SIX MONTHS. _________________ (to be filled in by Road to Success staff)*

I have read and understand the above statement.
State of Ohio regulations require all training be made available within SIX MONTHS. _________________ (to be filled in by Road to Success staff)
State of Ohio regulations require all training be made available within SIX MONTHS. _________________
blanks
Should a student be unable to attend available training sessions offered from the JCESC Office, the school is relieved of the aforementioned obligation. The Driving School shall furnish a licensed instructor and a motor vehicle for instruction. The tuition for said instruction is $350. Any additional in-car training may be obtained at the hourly rate of $50 per hour.*

I have read and understand the above statement.
The Student is required to have a valid temporary driving permit and pay tuition in full prior to being scheduled for the behind-the-wheel training. If the Student must change or cancel a scheduled driving appointment, the request must be made via email to roadtosuccess@jcesc.org at least 72 hours prior to the scheduled driving appointment. Changes and cancellations that do not occur prior to 72 hours of scheduled driving appointment will result in a $50 cancellation/re-scheduling fee. The same $50 fee shall apply should the Student fail to appear, or for any reason not be prepared to take the scheduled lesson (no permit). The Driving School reserves the right and must deny the Student admittance to any class if the Student is tardy. Should a check received for payment of tuition in whole or in part, be returned due to insufficient funds; the Student may be removed from the driving schedule until such a check is made good. An additional fee of $50 is charged for any returned check.*

I have read and understand the above statement.
Should a student be unable to attend available training sessions offered from the JCESC Office, the school is relieved of the aforementioned obligation. The Driving School shall furnish a licensed instructor and a motor vehicle for instruction. The tuition for said instruction is $350. Any additional in-car training may be obtained at the hourly rate of $50 per hour.
The Student is required to have a valid temporary driving permit and pay tuition in full prior to being scheduled for the behind-the-wheel training. If the Student must change or cancel a scheduled driving appointment, the request must be made via email to roadtosuccess@jcesc.org at least 72 hours prior to the scheduled driving appointment. Changes and cancellations that do not occur prior to 72 hours of scheduled driving appointment will result in a $50 cancellation/re-scheduling fee. The same $50 fee shall apply should the Student fail to appear, or for any reason not be prepared to take the scheduled lesson (no permit). The Driving School reserves the right and must deny the Student admittance to any class if the Student is tardy. Should a check received for payment of tuition in whole or in part, be returned due to insufficient funds; the Student may be removed from the driving schedule until such a check is made good. An additional fee of $50 is charged for any returned check.
The Student is required to complete all available training within six months of the date the contract was signed. No student is permitted to complete more than four hours of online and behind-the-wheel training in a twenty-four hour period. The Driving School will make available any remaining behind-the-wheel training once the student provided proof of completion of an online driver education program. There may be no refunds provided after that time. Upon expiration of this agreement, a reinstatement fee of $200 will be charged before any further services are provided. The Driving School does not guarantee the issuance of a driver license to the Student. Students are unable to use the Driving School vehicles for the final test at the Drivers Examination Station.

The Driving School reserves the right to cancel this agreement at any time, should the 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 of abuse is strictly prohibited. Should this agreement be cancelled under such circumstances, all fees may be pro-rated, $75 per hour, based upon hours of service provided prior to cancellation.

The Driving School shall furnish a certificate of completion to all students under the age of eighteen years, who successfully complete the course. Completion, as defined by the State of Ohio, refers to the completion of the required 24 hours of online and the student’s good-faith effort having been exercised during the 8 hours of practical driving.
Commercial Driving schools are licensed by the Department of Public Safety through the Driver Training Program Office; 1970 West Broad Street, Columbus, Ohio, 43223. Valuable information for parents and teenagers is available on the internet at www.drivertraining.ohio.gov under Parents and Teens.
The Student is required to complete all available training within six months of the date the contract was signed. No student is permitted to complete more than four hours of online and behind-the-wheel training in a twenty-four hour period. The Driving School will make available any remaining behind-the-wheel training once the student provided proof of completion of an online driver education program. There may be no refunds provided after that time. Upon expiration of this agreement, a reinstatement fee of $200 will be charged before any further services are provided. The Driving School does not guarantee the issuance of a driver license to the Student. Students are unable to use the Driving School vehicles for the final test at the Drivers Examination Station.The Driving School reserves the right to cancel this agreement at any time, should the 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 of abuse is strictly prohibited. Should this agreement be cancelled under such circumstances, all fees may be pro-rated, $75 per hour, based upon hours of service provided prior to cancellation.The Driving School shall furnish a certificate of completion to all students under the age of eighteen years, who successfully complete the course. Completion, as defined by the State of Ohio, refers to the completion of the required 24 hours of online and the student’s good-faith effort having been exercised during the 8 hours of practical driving.Commercial Driving schools are licensed by the Department of Public Safety through the Driver Training Program Office; 1970 West Broad Street, Columbus, Ohio, 43223. Valuable information for parents and teenagers is available on the internet at www.drivertraining.ohio.gov under Parents and Teens.*

I have read, understand, and retained a copy of this agreeement.
I have read, understand, and have retained a copy of this agreement.*

Yes
JCESC Driving School Official Printed Name (to be completed by JCESC staff):
JCESC Driving School Official Signature (to be completed by JCESC staff):

Clear
Date Signed (to be completed by JCESC staff):

MonthDayYear
Date
Student Printed Name:*
Student D.O.B.:*

MonthDayYear
Date
Student Signature:*

Clear
Date Signed:*

MonthDayYear
Date
Parent/Guardian Printed Name:*
Parent/Guardian Signature:*

Clear
Date Signed:*

MonthDayYear
Date
Upload your completed Drivers Education Coursework Certificate:*

Cancelof

EMERGENCY MEDICAL AUTHORIZATION
PART I – TO GRANT CONSENT
School District Name:*
Student Name:*

First NameMiddle NameLast Name
Student Date of Birth:*

MonthDayYear
Date
RESIDENTIAL PARENT or GUARDIAN
Primary Parent/Guardian Name:*

First NameLast Name
Primary Parent/Guardian Phone Number (Cell):*
Please enter a valid phone number.
Primary Parent/Guardian Phone Number (Home):
Please enter a valid phone number.
Secondary Parent/Guardian Name:

First NameLast Name
Secondary Parent/Guardian Phone Number (Cell):
Please enter a valid phone number.
Secondary Parent/Guardian Phone Number (Home):
Please enter a valid phone number.

CONSENT SECTION - Part II
In the event reasonable attempts to contact the above persons have been unsuccessful, I hereby give my Consent for the following medical care providers and local hospital to be called:
In the event reasonable attempts to contact the above persons have been unsuccessful, I hereby give my Consent for the following medical care providers and local hospital to be called: Doctor:*
Doctor Phone Number:*
Please enter a valid phone number.
Hospital:*
Hospital Phone Number:*
Please enter a valid phone number.
EMERGENCY SURGERY
This authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained BEFORE THE SURGERY IS PERFORMED

SPECIAL MEDICAL HISTORY
Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted:

(If none, please indicate, 'N/A' in the box below.)
EMERGENCY SURGERYThis authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained BEFORE THE SURGERY IS PERFORMEDSPECIAL MEDICAL HISTORY Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted: (If none, please indicate, 'N/A' in the box below.)*

I have read and understand the above statement.
Date Signed:*

MonthDayYear
Date
Parent/Guardian Signature:*

Clear

My Products*

Behind the Wheel In-Person Driving

$350.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Email address to receive invoice:
example@example.com
Should be Empty: