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Iowa Affidavit for School License Form

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Iowa Affidavit for School License Form
Iowa Affidavit for School License Form
Form 430021
12-13
OFFICE OF DRIVER SERVICES
License No.
Audit No.
Date
AFFIDAVIT FOR SCHOOL LICENSE
(to be completed by school)
NOTE: Iowa Code section 321.194 requires the school board or superintendent/principal to certify that a need exists for the license and that the board
and superintendent/principal are not responsible for actions of the applicant which pertains to the school license. The fact that the applicant
resides less than one mile from the applicant's schools of enrollment is prima facie evidence of the nonexistence of necessity for issuance of a
license.
Prima facie means that the one-mile requirement is waived only when the school official has reviewed an application and has determined that
a special or extraordinary circumstance exists. A blanket waiver of the one-mile requirement is not appropriate.
STATE OF IOWA )
)
COUNTY OF
)
It is deemed necessary that
of be issued a school license to attend duly
scheduled courses of instruction or extracurricular activities at
I certify that the school is an accredited school, or school that uses licensed practitioners as instructors, in the district of residence of the
applicant's parent or guardian or in a contiguous district if open enrollment criteria established in Chapter 282 applies; that the applicant
lives at least one mile from the school, or
lives less than one mile from the school, but according to policy the school board has determined that a need exists for the
school license
and has successfully completed an approved driver education course or has qualified for a driver education hardship exemption; that
the duly scheduled courses of instruction are prescribed by the school board or required by statute; and that the extracurricular activities
are sponsored by the school board.
I, the undersigned, hereby certify under penalty of perjury and pursuant to the laws of the State of Iowa that all of the
preceding is true and correct. I further certify that the school board and the superintendent/principal are not responsible for
actions of the applicant which pertain to the use of the school license.
Superintendent, Principal or School Board Chairperson
Date
Applicant's Full Name
School(s)
School(s)
NOTE: Iowa Code section 321.194 requires an applicant for a school license to successfully complete an approved driver education
course before the license may be issued. The requirement may be waived if the applicant demonstrates to the satisfaction of
the department that completion of the course would impose a hardship as defined in subrule 602.17(3), Iowa Administrative
Code. Hardship means:
(1) If the applicant is 14 years old, that a driver education course will not begin at the applicant's school(s) of enrollment or
at a public school in the applicant's district of residence within one year following the applicant's fourteenth birthday; or
(2) If the applicant is 15 years old, that a driver education course will not begin at the applicant's school(s) of enrollment or
at a public school in that applicant's district of residence within six months following the applicant's fifteenth birthday; or
(3) If the applicant is between 16 and 18 years old, that a driver education course is not offered at the applicant's school(s)
of enrollment or a public school in the applicant's district of residence at the time the request for hardship status is
submitted to the department.
(4) If the applicant is permanently handicapped and is unable to walk in excess of 200 feet unassisted or cannot walk without
causing serious detriment or injury to the applicant's health.
APPLICATION FOR EXEMPTION FROM DRIVER EDUCATION REQUIREMENT
Date
Date
Date
Year
Year
Year
Applicant's Full Name
is permanently handicapped and is unable to walk in excess of 200 feet
unassisted or cannot walk without causing serious detriment or injury to the applicant's health.
We, the undersigned, hereby certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding
is true and correct.
Applicant's Full Name
became years of age on
The last driver education class began , , and the next driver education class will not begin
until
, .
Date
Date
Parent or Guardian
Superintendent, Principal or School Board Chairperson
Iowa Affidavit for School License Form
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