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

CityState / Province

Postal / Zip Code
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*

MonthDayYear
All teen registrations must be 14 years 10 Months in age or older
Date of Birth*

MonthDayYear
All adult registrations must be 18 years in age or older
High School*
Do you year corrective lenses?*
Contact Details
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Mobile Phone*

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

Area CodePhone Number
Parent Mobile Phone*

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

Area CodePhone 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

CityState / Province

Postal / Zip Code

New Driver Registration
Payment Confirmation
SafeWay Driving Location Details:

{driveSite}

{driveSitedesc}

{driveSiteaddress}

Package Details:

{package}

{shipping}

Total*

USDFinal 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: