Insurance Reduction Certificate Course Registration

1
Please tell us about yourself.* This field is required.The information on this form is collected in accordance with Alberta's Personal Information Protection Act (PIPA). Please see our website at www.archersbluecar.ca for our full privacy policy.
First Name
Middle Name
Last Name
2
Are you (Student) over 18?* This field is required.
YESNO
3
Name of Parent/Legal Guardian
First Name
Last Name
4
Where do you live or want to be picked up?* This field is required. Your mailing address/ lesson pick-up address. Elaine will be assigned as the instructor for Students wanting to be picked up and/or dropped off in Fort Saskatchewan, Sherwood Park, Gibbons, Bon-Accord or Redwater (Private lessons only). For value lessons, student must live or meet in the free pick up area.
Street Address
Street Address Line 2
City
State / Province
Postal Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Is there somewhere else you want to be picked up for your lessons?
YESNO
6
Secondary Address
Street Address
Name of location ie: School, work place, LRT station...
City
State / Province
Postal Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Student's Phone Number* This field is required. If the student does not have a cell phone, please put a number where we can reach the student
Area Code
Phone Number
8
The phone number is:
Cell
Home
Work
9
Do you want to receive a text lesson reminder?
YESNO
10
Email* This field is required.This e-mail will be used as the login for our online calendar, receive lesson reminders and will be used as the contact e-mail for our online course provider if applicable.
example@example.com
11
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
12
Emergency Contact (Name and relationship):* This field is required.
13
Current License Class
None
Class 7 (Learner's)
Class 5 GDL
Class 5 Full
Other Province
Other Country
14
Date License Was Issued* This field is required. This will also be used as the password for the online calendar, if applicable. If not sure just leave today's date
Date
Year
Month
Day
15
Expiry Date on the License
Date
Year
Month
Day
16
Type of Classroom for Insurance Reduction Course* This field is required.15 hours of Classroom Training is required to get the Insurance Reduction Certificate..
In-Person classroom at NAIT $55 (Next Classroom to be determined Pending COVID Restrictions)
Online classroom $55 (Free upgrade until further notice)
17
Does the Student already have basic vehicle control? This question is to assist you and deciding how many lessons hours might be needed. This is only a suggestion.
Definitely will need help figuring out vehicle control, has no driving experience and/or does not yet have basic control (Will most likely need more than 10 hours)
Has done some parking lot driving, but pretty limited control, still figuring out timing for turns (Will likely need more than 10 hours)
Can do basic lane driving and turns in residential at 30 to 40 kph (may need more than 10 hours)
Can do lane driving including smooth turns and lane changes to 50 kph (might not need more than 10 hours)
Can do lane driving including smooth turns and lane changes to 60 kph (Likely will not need more than 10 hours)
18
Select Vehicle Transmission Type
Automatic
Manual (MUST TAKE 14 HOURS OR 20 HOURS PACKAGE)
Mix of both (MUST TAKE 14 HOURS OR 20 HOURS PACKAGE)
19
Private Lessons In-Car Hours options* This field is required.If a student whishes to upgrade to a higher package, only the difference between packages will be charged. Ex the difference between a 10 and 14 hours package is $195
10 Hours ($544 total, $54.50/Hour)
14 Hours ($739 Total, $52.79/Hour)
20 Hours ($999 Total, $49.95/Hour)
20
Instructor PreferenceMeet the Instructors/
None/First Available
Female Only (Elaine or Kelly)
Francophone Instructor (Dom)
Carol Independent Female Contractor
21
Is there anything else that would be helpful for the instructors to know about the student?(ex: particular anxieties, learning preferences, etc.)
Huge
Large
Normal
Small
Ok
Ok
22
Do you wish to use our car for your Basic Road Test?Please note that the car can be used for the road test as part of the 14 or 20 hours lesson options.
No
Yes, with 45 minutes pre-test warm-up drive 99.99
23
Have you booked your road test yet?
YESNO
24
When and at what time? Please put the test actual start time
Date
Year
Month
Day
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
PM
AM
PM
25
Where is the road test?
Name of Registry
Address of the Registry
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
26
Method of Payment Options
E-Transfer
Cash or Cheque in person ($95 Classroom fee must be pre-paid online, payments must be made at the beginning of the lesson)
Debit Card or Credit Card in person ($95 Classroom fee must be pre-paid online, payments must be made at the beginning of the lesson, +3% for credit card)
Visa, Master Card online (+ 3%)
PayPal online (+ 3%)
Visa Debit, MC Debit (+3%)
Credit card over the phone (+3%)
27
Which payment option do you plan to use?
Pay in Full
Pay in 2 parts ( Pay half for the in-car portion up front, 2nd half due at the mid-way point of the lessons)
Pay as you go ($95 upon registration, pay for the 1st and last lessons, remaining payments will be divided in equal payments of $100)
28
Your Total PricePay 1/2 or Pay as You Go payment options are not applied in this field
29
Is the person paying for the lessons the same as the person registering?This person will be receiving the invoice(s) and receipts.
YESNO
30
Name of person making the payment(s)
First Name
Last Name
31
E-Mail of person making the payment(s)
example@example.com
32
Phone Number of person making the payment(s)
Area Code
Phone Number
33
How have you heard about us?Select all that apply
Seen our distinctive looking cars
Friend or family referral
Online search
Online Ad
YouTube Videos
Facebook
34
Any questions or comments?
Huge
Large
Normal
Small
Ok
Ok
35
* This field is required.
36
Name of person agreeing to the terms and conditions.* This field is required. Student if over 18 or parent/legal guardian
First Name
Last Name
37
Date* This field is required.
Date
Year
Month
Day
Should be Empty: