TEST – Holman's Driving School

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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