Driving School of North Texas

DRIVING SCHOOL OF NORTH TEXAS, LLC (C2128)

Student Enrollment

Student Information Only

* Indicates field is required

*Last Name:
*First Name:
Middle Initial:
Sex:	Male Female

*Phone Number:

eg: xxx-xxx-xxxx

*Email:

*Date of Birth:

*Student.s Address:
City:
State:
Zip Code:

Parent Cell:
Student Cell:
Other Cell:
*High School Name:

Fees and Services

Services

1. Driver Education (32 hrs Class & 14 hrs In-Car)

2. Shuttle Service - ride from local high schools

3. Adult 6hr DE Course

Select
	$405.00


	N/C

	$99.00

Other Services

1. Classroom Instruction Only

2. In-Car Instruction Only

Total Fees & Services:


		$250.00
		$300.00

Class Enrollment

*School Location:	McKinney	*Start Date:
	Frisco	*Start Time:
	Allen

School may terminate Student’s enrollment if Student accumulates absences in excess of 5 days of scheduled classroom hours. Driver Permit may be revoked if classroom is not completed within one hundred (180) days. The Parent and Student agree that all classroom and in-car lessons must be made-up/completed within the 180 days of the classroom beginning date.

*Initials:

Other Charges & Fees

Failure to pick up your student on-time after the first 15 minutes

No Show Fee for failure to cancel drive time 24 hrs in advance

Returned checks (for any reason)


$25.00

$25.00

$30.00

*Initials:

I agree to the Terms and Conditions

	Accept	Decline

Disclosure

Does your student currently have or had ever been diagnosed with or treated for any medical condition that may affect his/her ability to safely operate a motor vehicle?

Within the past two years, has your student been diagnosed with, been hospitalized for or currently being treated for a psychiatric disorder? Examples included but not limited to ADHD, ADD, epileptic seizure, convulsion, loss of consciousness or other seizure.
If yes please explain :

Payment Details

Payment Form:
Credit card #:	eg: xxxx-xxxx-xxxx-xxxx

Code:	eg: xxx
Expiration Date:	eg: (mm / yy)

E-Mail a Copy to: