Name:_________________________________________________________________________ Parent/Guardian’s Name:_________________________________________________________ Address________________________________________________________________________ City, State, Zip:__________________________________________________________________ Phone:_________________________ E-mail Address__________________________________ I have my: Driver’s Permit / Restricted License (circle one) Please complete and return this form along with your $340.00 fee to secure a space in the class. Please make check payable to South Dakota Safety Council. You must attend a Defensive Driving and a Rules of the Road class before starting your behind-the-wheel lessons. You must also have your learners permit before starting behind-the-wheel lessons. June Rules of the Road: June 11, 2009 - Thursday 5:30pm to 8:30pm Defensive Driving: June 15, 2009 - Monday 5:30pm to 9:30pm July Rules of the Road: July 7, 2009 - Tuesday 5:30pm to 8:30pm Defensive Driving: July 11, 2009 - Saturday 8:00am to 12:00pm Rules of the Road: July 16, 2009 - Thursday 5:30pm to 8:30pm Defensive Driving: July 23, 2009 - Thursday 5:30pm to 9:30pm August Rules of the Road: August 4, 2009 - Tuesday 5:30pm to 8:30pm Defensive Driving: August 8, 2009 - Saturday 8:00am to 12:00pm Rules of the Road: August 13, 2009 - Thursday 5:30pm to 8:30pm Defensive Driving: August 20, 2009 - Thursday 5:30pm to 9:30pm September Rules of the Road: September 8, 2009 - Tuesday 5:30pm to 8:30pm Defensive Driving: September 12, 2009 - Saturday 8:00am to 12:00pm Rules of the Road: September 19, 2009 - Saturday 9:00am to 12:00pm Defensive Driving: September 24, 2009 - Thursday 5:30pm to 9:30pm Our program does NOT reduce the 180-day waiting period between getting a Learner’s Permit and getting a Restricted License nor do we license drivers (students need to schedule the drive test with the DMV once their 180-days are up if they want a Restricted License). For more information, please contact Diane at 605-361-7785 or e-mail dhall@southdakotasafetycouncil.org.
This form must be filled out and signed by the applicant, (participants under the age of 18 years must have a parent or legal guardian sign also) before beginning a driving program. Name ________________________________________________________ Home Address _________________________________________________ City _________________________________________ State _____ Zip____ Phone _____________________________ Date of Birth_________________ The undersigned participant and his or her parent or legal guardian, if the participant is under the age of 18 years, does hereby execute this release, waiver and indemnification for themselves and their heirs, successors, representatives and assigns; and hereby agree(s) and represent(s) as follows: To release the South Dakota Safety Council, its members, employees, agents, and reprehensive form any and all liability, loss, damage, costs, claims and/or causes of action, including but not limited to all bodily injuries and property damage arising out of participation in any driving program. The undersigned further agree(s) to indemnify the South Dakota Safety Council, its employees, members, agents, and representatives and hold them harmless for any liability, loss damage, cost, claim, judgment or settlement which may be brought or entered against them as a result of the undersigned's participation in any driving program. This indemnification shall include attorney's fees incurred in negotiating any settlement. It is understood and agreed that the undersigned shall have the opportunity to consent to any such settlement, provided, however that such consent shall not be unreasonably withheld
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Contact the South Dakota Safety Council at sdsc@southdakotasafetycouncil.org or phone 605-361-7785/800-952-5539.