Modern Driver Institute

Proudly serving the neurodivergent community since 2014

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Enroll

Enroll

We are happy to have you as a client! Please complete the form below and click “submit”. We will be in touch with you shortly to schedule. Please be sure to read the Service Terms and Privacy Policy.

Enrollment Form

Name of Client (the individual who will be driving) *

First

Last *

Last

Client Address (where lessons will be provided)

City

State/Province

Zip/Postal

Country

Primary Contact Email *

Primary Contact Phone Number

The Client is:

Under 18 (a minor)

18 or over

If the Client is represented by a parent or guardian, please identify. *

Please check any boxes which apply.

Autism Spectrum Disorder (ASD) [this includes earlier diagnoses of Asperger’s and PDD-NOS]

Anxiety

ADD or AD/HDADD or AD/HD

Tourette Syndrome

Cerebral Palsy

Down Syndrome

Fragile X Syndrome

Dyslexia

Dysgraphia

Bipolar

Schizophrenia

OtherOther

If you indicated “other” above, please specify.

Does the client have any allergies which require the use of an Epi-Pen?

Yes

Does the client have any physical limitation which require adaptive equipment in the vehicle?

Yes

Does the Client currently possess a valid PA learner’s permit or a driver’s license issued by any state?

Yes

Does the Client have any history of car crashes?

Yes

If you answered yes to the question above, please provide additional detail.

Captcha

If you are human, leave this field blank.