Driver Improvement (Defensive Driving)

Driver Improvement (Defensive Driving)
Payment Options *

Credit Card Check payment (Payment required for every order, must receive within 48 hours for order to be complete. We are unable to hold a seat if not received within 48 hours. )
Course Options

February 27, 2021 April 10, 2021

Credit Card Info: *

February 27, 2021 -- Full Payment $ 95.00

April 10, 2021 -- Full Payment $ 95.00

Total $ 0.00

General Information
Parent/Guardian (if applicable)

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Student Information
Driver's Name *

First Name Last Name
Birth Date *

Month Day Year
School Name
Grade
Gender *

Male Female
Student Permit/License # *
Expiration Date *

Month Day Year
Date
Student's Phone

Area Code Phone Number
Does the driver have any special accommodations we should be aware of (504 Plan, IEP, etc.)? If yes, please describe. *
Special Accommodations Information
Refund Policy

Towne Lake Driving School does not offer refunds. All contracts are good for one (1) year.
Confirmation

BY CLICKING THE SUBMIT BUTTON, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE. I ALSO CONFIRM THAT I AGREE WITH TOWNE LAKE DRIVING SCHOOL'S PRIVACY POLICY.
Should be Empty: