SIGN UP

Use the following form to sign up.

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

Class Date Choice

Class Choice *

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

Payment Method *

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.

Referred by

If someone referred you to this program please put their name and address (if you know it) in this box. This is not required.

Car *

Students will be driving a Ford Fiesta, Ford Taurus or Nissan Versa that is an automatic and has a driver 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.