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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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