Keys 4 Safe Driving Registration Form

Louisiana Department of Public Safety and Corrections
DRIVER EDUCATION REGISTRATION AND COURSE FORM
DRIVING SCHOOL INFORMATION
KEYS 4 SAFE DRIVING SCHOOL. LLC-1205

1910 OAK PARK BLVD. LAKE CHALES, LA, 70601

COURSE INFORMATION- check the course requested
TODAY'S DATE:

MonthDayYear
Date
Driver Education*

14 HOUR COURSE (18 Yrs. old & up) TOTAL: $46538 HOUR COURSE (17 Yrs. Old) TOTAL: $46538 HOUR COURSE (14 Yrs. & 9 months-16 yrs. old) TOTAL: $405Defensive Driving Course: $110
PLEASE PICK WHICH CLASS DATE(S) THE STUDENT WILL BE ATTENDING!*
STUDENT INFORMATION
Name of Student (PRINT First/Middle/Last)*
*PLEASE FILL OUT THE STUDENT'S FIRST, MIDDLE, AND LAST NAME*
TIP #:
TIP Issue Date

MonthDayYear
Date
Address*

Home Address

Street Address Line 2

CityState

ZIP Code
Date Of Birth*

MonthDayYear
Date
AGE*
Grade
High School Attending (Must be in at a minimum in the 8 grade)
Home Phone
Parent’s Cell*
Student Cell*
CONTACT PHONE NUMBERS
Email*
example@example.com
Please upload a picture of the TIP card (if you have one) or your state I.D. for verification of correct spelling of name and information.

Cancelof
STUDENT’S DRIVING EXPERIENCE
Describe locations where you have driving experience. (Check all that apply)*

NoneSubdivisionParking LotsRural RoadsIn TownHighwayInterstate
PARENTAL/GUARDIAN CONSENT- TO BE COMPLETED IF STUDENT IS A MINOR (14, 15, 16, OR 17 YEARS OF AGE ONLY)
I do hereby certify that I am the Legal Parent/Guardian of the minor applying and this is my authorization to the above named Driving School to administer the driver education course indicated above. I also declare by my signature below that the information I provided is complete and accurate.
Signature of Legal Parent/Guardian:*

Clear
Today's Date:

MonthDayYear
Date
SECURE YOUR SPOT TODAY! *
prevnext( X )
DepositTo secure your spot for a class, you must pay the non-refundable deposit to complete the process. If the payment is not made, the student will not be registered for an upcoming class. All remaining balances must be paid in full at least 4 days before the first day of class. We will send a reminder text prior to the payment date. **ALL online deposits are $50 + a processing fee of $5.00 **
$55.00

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Louisiana Department of Public Safety and Corrections

DRIVER EDUCATION REGISTRATION AND COURSE FORM

DRIVING SCHOOL INFORMATION

STUDENT INFORMATION

CONTACT PHONE NUMBERS

STUDENT’S DRIVING EXPERIENCE

PARENTAL/GUARDIAN CONSENT- TO BE COMPLETED IF STUDENT IS A MINOR (14, 15, 16, OR 17 YEARS OF AGE ONLY)