Registration Form: Mentoring, Test Prep, Lessons, MVA Test

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:
Learner's Permit Expires:
Date of Birth: mm/dd/yyyy

Course Information
Student is registering for:

MENTORING PACKAGE (can purchase as many packages as needed)

$569.99 --10 Hour discount package. Five days for 2 hours each day.

$349.99 --6 Hour discount package. Three days 2 hours each day.

$ 125.00 --2 Hours to be completed in one day or session.

$119.99 --One Test at the M.V.A. to obtain a Driver's License. Must be a former student of EMDS.

$139.99 --One Test at the M.V.A. to obtain a Driver's License. Non-EMDS driver education student

OTHER

$97.00 --Per 1.5 hour lesson.

$399.99 --Virginia Teens Only-36 hours classroom and 7 periods of driving and 7 periods of observation and tes


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. All fees are due at time of service
  2. When paying by check for packages or test, payments must be received in office and cleared by bank prior to starting lessons or taking test
  3. Through it tries not to change/cancel scheduled appointments, there are times when it is necessary to do so. Therefore, EMDS reserves the right to change/cancel driving appointment
  4. Student is required to provide at least 24 hours notice to cancel/change appointment
  5. Package lessons are scheduled as follows:
    1) 5 hour mentoring: Two sessions/2 hours each, plus one session/1 hour
    2) 10 hour mentoring: Five sessions/2 hours each
    3) 6 hour mentoring: Three sessions/2 hours each
  6. Excessive failure of student to give notice of canceling appointments may result in student's account being charged for lesson. (EMDS will notify student that charge will occur before doing so)
  7. Refunds: EASY METHOD DRIVING SCHOOL offers no refunds for this course.

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