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Segment 2 Contract / Registration
Please complete this form to be registered for segment 2 drivers training. Please note that all communication will be through this email. Please ensure that you enter this correctly! 
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Email *
Please select requested month of classes. *
Students Full Name *
Date Of Birth *
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/
DD
/
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Age *
Students Drivers License Number *
Students Drivers License Issue Date *
Address *
Parent / Guardian Name *
Parent / Guardian Address *
Student Email *
Student Cell number *
Parent Email *
Parent Cell number *
Emergency Contact *
Course Provisions
Segment 2 payment in the amount of $100 is due at time of registration.
30 Hour Certification
I certify that my student has logged at least 30 hours of practice driving (2 hours of which occurred at night) with myself, another parent (or guardian) or a designated driver over the age of 21. By submitting this form you are electronically signing.

By adding your name you are signing this contract and agreeing to full terms as stated above. Parent or Guardian signature: *
A copy of your responses will be emailed to the address you provided.
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