Crowley V Drive Adult Registration

DRIVER EDUCATION REGISTRATION AND COURSE FORM
Tuition and fees are non-refundable. Only one rescheduling of class dates will be allowed. Each additional reschedule will incur a $100 fee. Once class begins, tuition is considered earned in full. No refund or course credit will be given for any course dropped due to attendance, behavior, or other issues. Deposits are non-refundable.
By registering below, I understand and agree to the above Policies and Procedures
Please Choose Class Dates for Crowley V Drive
STUDENT INFORMATION
Name of Student (PRINT First/Last)

First NameLast Name
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age (must be 18 or older)
Address

Street Address

CityState / Province

Postal / Zip Code
TIP Number (please leave blank if you have not gotten one yet)
TIP Issue Date (please leave blank if you have not gotten one yet)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Email Address
example@example.com
CONTACT PHONE NUMBERS
Primary Contact
Format: (000) 000-0000.
Secondary Contact
Format: (000) 000-0000.
Alternative Contact
Format: (000) 000-0000.

Crowley Adult Course Full Balance

($400 plus 4% convenience charge)

$416.00

Crowley Adult Course Deposit

($100 plus 4% convenience charge)

$104.00

Total

Credit Card

Apple Pay

Google Pay

Cash App Pay

Last 4 of Deposit Card Number:
Class Information
Notes:
Certificate Number
Classroom Begin Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name of Classroom Instructor/Examiner
Classroom Completion Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Fees Received:
Payment
Check #, Cash Receipt #, Last 4 of Card #,
Balance (only if on pmt pln)
ONLY IF STUDENT HAS A TIP CARD AND IS NOT ON A PAYMENT PLAN
Student CID Number:
Date K2D Passed:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent Consent Signatures
Fee Breakdown:
Classroom Fee
Behind the Wheel Fee
Total Course Fees
Date/Time Deposit Paid:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Amount Credited:
Should be Empty:

DRIVER EDUCATION REGISTRATION AND COURSE FORM