Registration Form: Driver's Education Course

Personal Information
First Name:
Middle Name
Last Name:
Address:
Address 2:
City:
State:
Zip:
Phone Number: xxx xxx xxxx
Email Address:
Re-enter Email Address:
Learner's Permit Number: If you do not have a Learner's Permit yet, leave this field blank and initial the Learner's Permit disclaimer at the bottom of this order form.
Place of Birth:
Date of Birth: mm/dd/yyyy

Course Information
Classroom Date, Time, and Location
Parent / Mentor will attend orientation session (first class)
will NOT attend orientation session (first class)

Course Options
Student is registering for:


 PLAN 1- $319.99  SPECIAL PRICE FOR ALL CLASSES STARTING MARCH 2010. ( HIGH SCHOOL LOCATIONS NOT INCLUDED) SEE SCHEDULES FOR LOCATIONS NEAR YOU!

 PLAN 2 - $329.99  SPECIAL PRICE FOR CLASSES STARTING APRIL 2010. (High School locations not included)SAVE OFF REGULAR PRICE- SPECIAL IS GOOD FOR SHERWOOD, PAINT BRANCH, AND GAITHERSBURG HIGH SCHOOLS ALSO. ALL OTHER HIGH SCHOOLS SEE PLAN #4

 PLAN 3 - $349.99  SPECIAL PRICE FOR CLASSES STARTING IN MAY 2010. ( REGULAR PRICE $399.99 SAVE $50.00) HIGH SCHOOL LOCATIONS NOT INCLUDED.


Payment Information
Cost Total: $
Charge Type: VISA
MASTERCARD
DISCOVER
AMERICAN EXPRESS
Card Number:
Expiration Date: (MM/YYYY)
Cardholder Name
CVV2 For AMERICAN EXPRESS enter the 4 numbers on the front top right corner. For all other cards, please enter the last 3 numbers on the back side of your card.

Policies
By initialing below, I agree to the following EASY METHOD DRIVING SCHOOL policies:
  1. Student is required to attend, participate and pass all required classes and in car sessions.
  2. When student cancels an appointment with less than 24 hours notice, all future appointments will be cancelled until a cancellation fee of $30.00 is paid.
  3. All fees are to be paid at time of service. Student is responsible for all fees prior to completion of course.
  4. Student will not be considered registered for a course until payment is received.
  5. The Driver Education Course may take longer than 18 weeks to complete.
  6. If course is not completed within 12 months, the student will be assessed an additional fee of $30.00 per month for each past due month.
  7. A $10.00 fee will be charged for redeposit checks; $25.00 fee for returned checks
  8. Though Easy Method Driving School tries not to change class or driving times, there are times when it is necessary to do so. Therefore, EMDS reserves the right to change the scheduled dates of classes (includes in car sessions.)
  9. Refunds: Easy Method Driving School will issue a full refund if request is submitted, in writing, 72 hours prior to the start of the program. If less than 72 hours, but before the first day of class, a fee of $99.95 will be deducted from the refund. No refund will be issued after class begins.

I agree: Student's Initials,  Parent / Guardian Initials (for under 18 student)
Learners Permit Students ONLY
For Students who do not have a learner's permit: To the best of my knowledge, I know of no physical, mental or legal reason why I would be unable to obtain a Maryland Learner's Permit.

Student's Initials,  Parent / Guardian Initials (for under 18 student)