EmailMe Form - Scholarship Recipient Registration Form

Thank you for choosing the CPTC Driver's Education course! This registration form is appropriate for students that have been awarded the GDEC Grant Scholarship and have a voucher code. All other students should register using the online Non-Scholarship Registration Form.

Once you begin this registration form, you cannot save the form and return to where you left off. Please have the following items prepared before beginning.
1. Print, complete, and sign the Course Frms available on our website.
2. Scan the completed Course Forms.
3. Save all pages of the course forms as ONE file that you can upload. If you are not able to upload the Course Forms during registration or need to upload multiple pages, please submit them using the UPLOAD DOCUMENTS feature under the Course Forms section on our website.
4. Copy, scan, or take a picture of the front of the student's driving permit and save it as a file that you can upload.

For timely processing of your registration, uploading the permit and Course Forms is recommended. You may elect to return these items by mail or in-person drop off, following the directions in the Course Information.

How did you hear about us?

Course Start Date *

MM / DD / YYYY

For the full Driver's Ed course schedule, visit our website: www.coastalpines.edu/driversed/

Campus *

Grant Scholarship Information

The GDEC awards scholarships one time per month on or around the first day of the month. If you have been awarded a scholarship, please continue this registration and complete the information below. If you have not yet applied for the scholarship, please visit the GDEC website at www.georgiadrivers.ga.gov to apply, then complete this registration once you receive a scholarship award from the GDEC. If you would like to pay out-of-pocket, please use the Non-Scholarship Driver's Education Registration Form link on our website.

Award Voucher Code *

Application Number *

Date of Award *

MM / DD / YYYY

Date you recieved the email from the GDEC awarding the scholarship.

Student Information

Please provide the STUDENT information in all fields in this section.

Name *

First Middle Last Suffix

Please provide legal name as shown on driving permit.

Address *

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

Phone

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

Email

Please do not use a school email containing .ga.us

Date of Birth *

MM / DD / YYYY

Age *

Name of High School *

Highest grate completed *

Upload Student's Driving Permit *

A valid driving permit is required for scholarship students and courses including BTWT. Please upload now!

Driving Permit Number *

Permit Issue Date *

MM / DD / YYYY

Permit Expiration Date *

MM / DD / YYYY

Upload course forms

To upload here, please complete and save the following course forms as ONE FILE:
Student Code of Conduct Acknowledgement
Student Class Release Form
Off Campus Leave Form
Release of Driving Information and Waiver (appropriate form based on student's age)
Cancellation and No-Show Form
FERPA Release
Driver Training Student Contract
Fee Submission Form

Forms are available on our website or can be requested by email at driversed@coastalpines.edu. To upload forms that are saved as multiple files, please use the UPLOAD DOCUMENTS feature under the Course Forms section of our website. Forms may also be mailed or dropped-off at any campus location following the instructions in the course information.

Gender* *

Female

Male

Are you Hispanic/Latino?* *

Yes

No

Decline to answer

Race* *

Are you a US Citizen?* *

Yes

No

Decline to anaswer

*Coastal Pines Technical College (CPTC) does not discriminate on the basis of race, color, creed, national or ethnic origin, gender, religion, disability, age, political affiliation or belief, genetic information, veteran status, or citizenship status (except in those special circumstances permitted or mandated by law).

Parent/Guardian Information

Please provide information for the PARENT or LEGAL GUARDIAN in all fields in this section.

Name *

First Last

Address (if different from student address)

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

Email *

Cell Phone *

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

Home or Work Phone

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

Emergency Contact

Name *

First Last

Relationship *

Phone *

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

Email

Thank you for choosing CPTC Driver's Ed!

Please be sure to read and understand the course information available on our website: www.coastalpines.edu/driversed/. Once your registration is processed, you will receive a confirmation email with information about your enrollment status. Enrollment is complete upon receipt of all course forms and successful redemption of the scholarship voucher.

We welcome your feedback!

For help, course forms, questions, or additional information, you may also email driversed@coastalpines.edu.