Student Phone Number ("None" if no phone available): *
Your answer
Street Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Parent Name (First and Last):
Your answer
Parent Phone Number ("None" if no phone available):
Your answer
School Attending ("Homeschool" or "None" if graduated): *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Permit Number ("NA" if no permit yet): *
Your answer
Driving Hours Logged (Approximate #): *
Your answer
License Eligibility Date (6 months from date of permit issue OR today's date if eligible now):
MM
/
DD
/
YYYY
Testing County (County where you will take your test):
Your answer
Medical Challenges (vision, health, anxiety, etc.) that may help us during driving instruction:
Your answer
I understand that I am agreeing to pay Fred Myers' School of Driving the student fee of $230.00 for 6 hours in-class instruction and 6 hours in-car instruction. (Additional hours of in-car instruction are available at a reduced cost)? *
Required
I understand that I must present my driving permit or license before driving sessions. *
Required
I understand that I must must call at least 24 hours in advance if I choose to cancel a schedule driving session. (Call to cancel: 270-443-FRED) *
Required
I understand and agree that I must complete this course within one year (12 months) or I may be charged additional fees. *
Required
I understand that this class is for the registered student and unused sessions are not transferrable to another student. *
Required
Signature (Type your name below to sign and authorize this registration): *