JRF Enterprises Ltd. dba
Mid-America Driver Training
530 Sand Ridge Rd.
Bowling Green, Oh.  43402

 Juvenile Driver Improvement Program

Name________________________________________________________ Date: _____________________

Address: ____________________________________________________City _______________________ 

State ____________________________Zip_________________Telephone# ________________________ 

Date of Birth_______________________SS#_________________________License#_________________

Classroom instruction will be held at 530 Sand Ridge Rd., Bowling Green, Ohio unless otherwise noted here: ______________________________________________________________________________________ 

FULL COURSE WILL CONSIST OF 6 HOURS OF CLASSROOM INSTRUCTION.  FULL COST OF THE COURSE IS
$100.00.  COURSE FEE IS NON-REFUNDABLE.  IF STUDENT IS UNABLE TO ATTEND HIS/HER SCHEDULED CLASS, FEE WILL BE CARRIED OVER TO NEXT AVAILABLE CLASS DATE. 

IT IS AGAINST THE LAW AND POTENTIALLY UNSAFE TO DRIVE TO THIS CLASS IF YOU ARE NOT IN POSSESSION OF A VALID DRIVER’S LICENSE OR PERMIT. 

MID-AMERICA DRIVER TRAINING SHALL FURNISH A LICENSED INSTRUCTOR FOR THE JUVENILE DRIVER IMPROVEMENT PROGRAM. DRIVER TRAINING SCHOOLS ARE LICENSED BY THE OHIO DEPARTMENT OF PUBLIC SAFETY, OHIO TRAFFIC SAFETY OFFICE,1970 WEST BROAD ST., PO BOX 182081, COLUMBUS, OHIO 43218-2018.

I HAVE READ AND UNDERSTAND THIS AGREEMENT: 

MID-AMERICA OFFICIAL_________________________________________________________________ 

PARENT OR GUARDIAN__________________________________________________________________

STUDENT________________________________________________________________________________

I, THE UNDERSIGNED INSTRUCTOR, CERTIFY THAT THE STUDENT HAS RECEIVED ALL CLASSROOM TRAINING REQUIRED BY RULE 4507.162 OF THE OHIO REVISED CODE.

INSTRUCTOR’S SIGNATURE_______________________________________________________________

PAYMENT:   AMOUNT DUE: $100.00
DATE_____________________________________AMOUNT PAID________________________________

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