Editing previous response:

Please fix the highlighted areas below before submitting.

On-the-Road Driver Education Instruction Registration Form

If you have any questions, please contact:

Alisha Kalapay
610-515-6403
[email protected]

STUDENT CONTACT INFORMATION

Student First Name*

Answer Required

Student Last Name*

Answer Required

Student Phone Number

Number Required

Student Email

Answer Required

Student Street Address

Answer Required

Student City

Answer Required

Student Zip/Postal Code

Answer Required

Student Date of Birth*

Answer Required

Student Grade*

Answer Required

Student High School*

Answer Required

PARENT CONTACT INFORMATION

Parent First Name*

Answer Required

Parent Last Name

Answer Required

Parent Email

Answer Required

Parent Phone Number

Number Required

Parent Street Address

Answer Required

Parent City

Answer Required

Parent Zip/Postal Code

Answer Required

PERMIT INFORMATION

Does the student have their permit?*

Answer Required

Yes

Effective date of student permit (type N/A if student doesn't have permit)*

Answer Required

Expiration date of student permit (type N/A if student doesn't have permit)*

Answer Required

Date student is eligible for the test

Answer Required

Please upload a picture of the student permit here.

Answer Required

Choose a file or drag it here.

Instructor Request*

Answer Required

Is an Accommodation under the Americans with Disabilities Act needed to participate in this training program? *

Answer Required

Yes

If answer is "yes" to question above, please provide more detail.

Answer Required

PAYMENT INFORMATION

Please click on the circle beside fee below to input your credit card information to complete the payment process. This is the only form of payment accepted.

Note that the email address in the "confirmation email" box below will be used for future correspondence regarding this registration.

On-the-Road Driver Education Instruction Fee*

Answer Required

$325.00

Confirmation Email

Confirmation Email *

Email Required