Welcome To Modern Driver Institute!

We’re happy to have you as a client!  First, please tell us a little about the person we’re going to be working with (if you’re a parent, please fill out the information for the student; if you’re an adult, please fill out the information for yourself).

Submitting a completed student enrollment indicates that you have read and agree to adhere to the Service Terms and Privacy Policy of the school.  Please take a moment to read these.

When  you’re finished, click “submit” and your instructor will call to get you set up with your first appointment.

Student First Name *

Please complete this field with the STUDENT's information.

Student Last Name *

Please complete this field with the STUDENT's information.

Student's Current Age *

Under 18

18-25

26-49

50 or over

Student's Height (in inches)

54

Street Address *

Just provide the house number and street name in this field. This is the address that will be used for lesson pickup and dropoff if you are within the service radius. If outside the normal service radius, this address will be used to find an appropriate meetup location.

Town *

Please enter the town in which you live.

Zip Code *

Please enter the 5 digit zip code number which matches the address you listed above.

PA County * AdamsAlleghenyArmstrongBeaverBedfordBerksBlairBradfordBucksButlerCambriaCameronCarbonCentreChesterClarionClearfieldClintonColumbiaCrawfordCumberlandDauphinDelawareElkErieFayetteForestFranklinFultonGreeneHuntingdonIndianaJeffersonJuniataLackawannaLancasterLawrenceLebanonLehighLuzerneLycomingMcKeanMercerMifflinMonroeMontgomeryMontourNorthamptonNorthumberlandPerryPhiladelphiaPikePotterSchuylkillSnyderSomersetSullivanSusquehannaTiogaUnionVenangoWarrenWashingtonWayneWestmorelandWyomingYorkOutside PA

Choose the county that matches the address you provided above. If you currently reside outside of PA, choose "Outside of PA" at the bottom of the list.

Phone (Please format as XXX-XXX-XXXX) *

This is the primary phone for whomever will be scheduling lessons. If the student is scheduling directly, please provide his/her best contact number. If a parent or guardian is handling scheduling, please provide the best contact number to reach him/her.

Email Address *

Does client have a valid learner's permit or driver's license? *

PA learner's permit

Driver's License (issued by any state)

No (currently a "theory" student)

Please note: the Commonwealth of Pennsylvania does not allow individuals with an out-of-state learner's permit to drive in Pennsylvania. As such, we are currently unable to offer services to students who are not PA residents.

Please check any and all relevant boxes. *

Anxiety

Autism Spectrum Disorder (includes Asperger's Syndrome and PDD-NOS)

Learning disabilities

Bipolar disorder

PTSD

Traumatic brain injury or stroke

Cerebral Palsy

Auditory Processing Disorder

Fragile X Syndrome

BPD (Borderline Personality Disorder)

Schizophrenia

None (Neurotypical)

OtherOther

Does the student have any serious or severe allergies which require the use of an Epi-Pen? *

Yes

No

Is the student diabetic? *

Yes, controlled by medicine only

Yes, controlled by insulin shots

No

Has the student or anyone in their immediate household tested positive for COVID-19 / Novel Coronavirus within the past five days?

Yes

No

Tell us a little about why you're here (driving background, any relevant medical conditions, crash history, et cetera).

I have read, understand and agree to the Service Terms and Privacy Policy. *Required

Option 1

I have read, understand and agree to the Service Terms and Privacy Policy.

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