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574.256.0650
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Frick's Driver Education School, Inc.
Student Registration Form
PLEASE PRINT FORM, COMPLETE, AND RETURN TO US EITHER VIA EMAIL>fricks@email.com
**Please note it is "E" mail.com Not "G"mail.com (Thx!)
Or,
YOU CAN MAIL IT TO US;
Or, YOU CAN DROP OFF IN PERSON
Date__________________________
Name as it appears on your Birth Certificate_____________________________________________________
Address________________________________________________City___________________________State______Zip_____________
Parent's Phone #__________________________________________________________________________
Student's Phone #_________________________________________________________________________
Student's Date of Birth_________________________________
Male________Female_________
Student's Email Address____________________________________________________________________________________________
Student's High School (if applicable)____________________________________________
Parent Info (If Student is Under 18 years of Age)
Parent or Guardian's Name______________________________________________________________
Additional Phone # if applicable_____________________________________________________
Parent's Email Address____________________________________________________________________________________________
Permit Info (Please provide the following if you have already obtained your permit)
Issue Date______________________
Driver's License Number (DLN)_______________________________________________________________________
Expiration Date___________________
Payment Info
Credit Card (Mastercard, Visa, or Discover) **If you prefer, you may phone in your payment info
DO NOT submit payment info thru this website
Credit Card Number__________________________________________________________________________
Exp. Date____________________3 Digit CVC________________
Name as it Appears on Card_______________________________________________________________________________________________________
Card Holders Signature________________________________________________________________________________________
Amount charged will be $475.00 which includes ONE of the following: (Please check desired Course)
_____One Online Course and Six Hours of Behind-the-Wheel Instruction
OR
_____Six Hours Only Behind-the-Wheel Instruction
OR
_____One Online ONLY Course (Charge will be $100.00)
OR
_____Individual In-Car Lesson(s) (Charge will be $80.00 per Hour)
OR
_____Fifty Hour Supervised Practice Driving (Charge will be $3900.00)
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