Registration

Please use the form below to register for services…

Parent or Guardian*

Do you have an email address?*

Yes

Email (We will use this to send you a copy of the registration for class)*

Son/Daughter ( If Adult Please Just type Adult )*

As it appears on Permit

Payment Method*

Class Choice*

Insurance Discount (Dependent on insurance provider) applies only if you take both Classroom and Behind the Wheel Classes.

Class Date Choice*

Student Name*

As Appears on Permit

Date of Birth*

Permit or License Number*

Issue Date*

Student Address*

Student Phone Number*

Cell Phone Number

If no cell number is available please put N/A in this field.

Vehicle Acknowledgement

I acknowledge and understand that students will be driving a Ford Taurus, Ford Focus, Ford Fiesta or a Toyota Scion that is an automatic and has an instructor brake on the passenger side.

Student Signature*

By placing your name in this text box you understand that this is your binding signature.

Parent/Guardian Signature*

By placing your name in this text box you understand that this is your binding signature.

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