SafeWay Driving New Driver Registration

New Driver Registration
Driver Type
Online Course
Package
Drive Site Location
Drive Site Description

Drive Site Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Shipping
Total
Registration Summary
SafeWay Driving Location Details:

{driveSite}

{driveSitedesc}

{driveSiteaddress}

Package Details:

{package}

{shipping}

Total: {total}
Driver Details
Legal First Name *
Legal Middle Name
Legal Last Name *
Nickname
Gender *
Date of Birth *

Month Day Year
All teen registrations must be 14 years 10 Months in age or older Date Picker Icon
Date of Birth *

Month Day Year
All adult registrations must be 18 years in age or older Date Picker Icon
High School *
Do you year corrective lenses? *
Contact Details

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone *

Area Code Phone Number
Mobile Phone *

Area Code Phone Number
Email *
example@example.com
Parent Information
Parent First Name *
Parent Last Name *
Email *
example@example.com
Parent Phone *

Area Code Phone Number
Parent Mobile Phone *

Area Code Phone Number
Insurance Company *
For potential insurance discounts
Emergency Contact Information
Same as Parent Contact Information
Name *
Phone Number *

Area Code Phone Number
Relationship to Driver *
Account Login Details

Please create a security question to be used to verify your identiity in case you forget your credentials. Your user name will be created by Safeway Driving which will be your first name initial and your full last name without spaces or special characters. Safeway will also create a temporary password for you. You will receive an email once you have completed the enrollment process with this temporary password and instructions on how to change this temporary password. You will also receive instructions on how to access your Driver Dashboard. Through your Driver Dashboard account you will be able to access your course information, schedule drives, and more.
Security Question *
This will be used to confirm your identity by SafeWay Driving in the event of lost credentials
Answer *
How did you find us?
How did you hear about SafeWay? *
Why did you decide to go with SafeWay? *
Special Needs

Please select Yes if there is any information that would be pertinent for our instructors to know when interacting with a student.
Has a Disability/Special Needs? *
Type of Disability
Description of Special Needs
Please share any detailed information that our staff and instructors should know when working with a student.

New Driver Registration
Shipping Details
Throughout your SafeWay Course you will receive two certificates.

Once upon successful completion of the online permit test and once upon successful completion of the course (online course and driving portion) a certificate will be mailed to the below address via priority mail.
At completion of your online course you will be mailed a certificate to the below address via priority mail.
Use Current Address

Shipping Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

New Driver Registration
Payment Confirmation
SafeWay Driving Location Details:

{driveSite}

{driveSitedesc}

{driveSiteaddress}

Package Details:

{package}

{shipping}

Total *

USD Final Payment Amount Owed

Credit Card Information (VISA, Discover, MasterCard accepted. AMEX not accepted at this time.)
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Your credit card will not be charged until after you digitaly sign and accept the terms and conditions of your contract on the following page.

New Driver Registration
Contract

Below is a sample contract for your selected driver training services through SafeWay Driving.

Upon completion of your enrollment you will be emailed a copy of your contract with your unique details included. Please allow 1 business day to receive your enrollment confirmation and temporary password to access your Driver Dashboard.
Teen Driver Terms and Conditions
Adult Driver Terms and Conditions
Signature *

Clear
Should be Empty: