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2022 West Elk Drivers Education Enrollment
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Student Information
Legal First Name
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Your answer
Middle Name
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Your answer
Second Middle Name (if applicable)
Your answer
Legal Last Name
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Your answer
Suffix (if applicable)
Your answer
Phone Number
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Your answer
Address Line 1: Mailing Address
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Your answer
Address Line 2: Street Address
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Your answer
City
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Your answer
Zip Code
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Your answer
Gender
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Male
Female
Date of Birth
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MM
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DD
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YYYY
Eye Color
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Your answer
Corrective Lenses
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Yes
No
Height (Ft)
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Your answer
Height (In)
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Your answer
Weight (lbs)
Your answer
Medical and Vision Questions
Vision Acuity: Right Eye 20/_____ (Must provide a copy of most recent vision test with enrollment) Fill in the number below:
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Your answer
Vision Acuity: Left Eye 20/____ (Must provide a copy of most recent vision test with enrollment) Fill in the number below:
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Your answer
Do you need vision correction?
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Yes
No
If you answered no to the previous question, provide the last date vision was checked:
MM
/
DD
/
YYYY
Do you have any physical limitations that may require car modifications?
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Yes
No
If you answered yes to the previous question, please describe:
Your answer
Do you currently have any physical, medical, vision, or mental condition(s) that could make it difficult to operate a motor vehicle safely?
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Yes
No
If you answered yes to the previous question, please list the name(s) of the condition(s) and medication(s) you take?
Your answer
Have you suffered a seizure in the last six months?
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Yes
No
If you answered yes to the previous question, please describe the type and list the occurrence date:
Your answer
License Questions
Are you a resident of Kansas?
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Yes
No
In the last 6 months, have you attempted and failed any testing 4 times at a Kansas Driver's License Exam Station?
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Yes
No
If you answered yes to the previous question, when?
MM
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DD
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YYYY
Are you currently a habitual user of drugs or alcohol?
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Yes
No
If you answered yes to the previous question, please describe:
Your answer
Do you have a current Kansas driver's license?
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Yes
No
If you answered yes to the previous question, please provide your driver's license number:
Your answer
Is your license now or has it ever been suspended/restricted/revoked in Kansas or any other state?
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Yes
No
I do not have a current license
If you answered yes to the previous question, please select a reason:
Choose
Suspension
Restriction
Revocation
If your license was suspended, restricted, or revoked, what was the date?
MM
/
DD
/
YYYY
Has your license/permit been surrendered to law enforcement due to the refusal or failure of a chemical test for drugs or alcohol?
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Yes
No
If you answered yes to the previous question, please describe:
Your answer
Is your license/permit suspended/canceled/revoked by any court pending review?
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Yes
No
If you answered yes to the previous question, please describe:
Your answer
Certification/Eligibility Questions
Are you lawfully present in the United States? (If you do not make such a declaration, you will not be permitted to proceed with this permit application).
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Yes
No
I hereby certify that giving false answers to any of these questions may be grounds for prosecution. My full legal name and today's date typed below represents my signature.
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Your answer
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