K4SD ONLINE - REGISTRATION FORM

KEYS 4 SAFE DRIVING REGISTRATION FORM
TODAY'S DATE: *

MonthDayYear
Date
Driver Education (Please choose the correct course based on the student's age)*

14 HOUR COURSE (AGE: 18 Yrs. old & up)38 HOUR COURSE (AGE: 17 Yrs. Old)38 HOUR COURSE (AGE: 14 Yrs. & 9 months-16 yrs. old)Defensive Driving Course: $110
Classroom Course Dates: *
Please select the class/course date you would like to attend for Driver's Education. For additional information, all class times are listed with the class dates on the website under the "Classes" tab. ***14 HOUR = ADULTS | 38 HOUR = TEENS****
STUDENT INFORMATION
Name of Student (MUST put the student's first/middle/last name) *
TIP #:
TIP Issue Date:

MonthDayYear
Date
Address*

Home Address

Street Address Line 2

CityState

ZIP Code
Date Of Birth:*

MonthDayYear
Date
CURRENT AGE:*
CURRENT GRADE:*
** If the student has a high school diploma, GED, or college degree please put N/A or graduated **
Current School Attending (Must be at least in the 8th grade)*
** If the student has a high school diploma, GED, or college degree please put N/A or graduated **
CONTACT PHONE NUMBERS & EMAIL
Home Phone:*
Format: (000) 000-0000.
Parents Cell:*
Student Cell:*
Email:*
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
I do hereby certify that I am the Legal Parent/Guardian of the minor applying, and/or if the applicant is an adult, I certify that the information provided is complete and accurate, and I authorize Keys 4 Safe Driving School to administer the driver education course indicated above.*
SECURE YOUR SPOT TODAY! *
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Deposit
To secure your spot for a class, you must pay the non-refundable registration fee 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 four days before the first day of class. We will send a reminder text before the payment date. **ALL online registration fees 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:

KEYS 4 SAFE DRIVING REGISTRATION FORM

STUDENT INFORMATION

CONTACT PHONE NUMBERS & EMAIL

STUDENT'S DRIVING EXPERIENCE

PARENTAL/GUARDIAN CONSENT- TO BE COMPLETED IF STUDENT IS A MINOR