EmailMe Form - Hoosier Driving Academy Class Registration Form

Student Name

First Last

Student Middle Initial

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parents' First Name

Parents' Last Name

Parent Email Address

Home Phone

### - ### - ####

Parent Mobile Phone

### - ### - ####

Student Date of Birth *

MM / DD / YYYY

Would you like a copy of the Code of Responsibilities emailed to you? *

Which type of class? *

Regular 30 hours in classroom plus 6 hours of behind-the-wheel ($435)

Online Drivingbrilliance.com 30 hours Internet plus 6 hours behind-the-wheel ($435)

Preferred Class Date *

Second Choice Date

What school do you attend?

How would you like to pay?

Credit Card (if selected, please go to web site to pay)

Check

Cash (must bring to office)