Name *

First Name

Last Name

Phone *

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have any restrictions?

Glasses or Contact Lenses

Language Barrier

Other

None

Date of Birth *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

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How did you hear about the event? *

News Article

Social Media

TV

Friend-Relative

Other

Payment Options *

Cashiers Check, Money Order (Payment to be made in office)

Debit/Credit Card Payment (To be payed now to complete transaction)

Refund Policy *

I understand and agree to the following refund policy: A full refund will be issued if cancellation is received within 30 days of registration. A partial refund of $195.00 will be issued if cancellation is received after the 30 days. Refunds may take up to 30 days depending on financial institution.

Permission to Participate PLEASE READ THIS CAREFULLY. THIS IS A LEGALLY BINDING AGREEMENT THAT AFFECTS YOUR RIGHTS AND OBLIGATIONS. IF YOU DO NOT UNDERSTAND THIS DOCUMENT, YOU SHOULD CONSULT WITH AN ATTORNEY BEFORE SIGNING. Indemnification and Hold Harmless: The STUDENT agrees, to RELEASE, REMISE, DISCHARGE, INDEMNIFY AND HOLD SAFETY COUNCIL, its members, officers, employees, driving instructors, workers and contractors, and agents HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages, losses, demands, personal injuries or deaths, and liabilities, including attorney's fees, brought by the STUDENT or any other person as a representative for STUDENT or by any other third party arising out of or related in any way to STUDENT'S participation in the PROGRAM. Permissions: BY CHECKING THIS BOX, The STUDENT gives permission to participate in a Drivers' Education program ("PROGRAM") being offered by the St. Joseph Safety and Health Council, Inc. ("SAFETY COUNCIL"). The Student further consents and agrees to allow SAFETY COUNCIL to obtain through a physician, ambulance service or hospital of its choice, such medical care as is reasonably necessary for the welfare of STUDENT. I/We represent and affirm that I/We are the legal guardian(s) of the student and warrant that I/We am of full age and have every right to contract for the student. I/We further agree that all the provisions of this document are equally binding upon the student, my representatives, heirs, assigns and next of kin. I/We further state that I/We have read the above permission to participate and that I/We are familiar with the contents of this document. *

By checking this box, you have read and affirm the Indemnification, Hold Harmless and Permissions and affirm the consent to participate. You are also releasing parties from liability and agreeing to indemnify them.

Cancellation Fee: *

I understand and agree to the following Cancellation fee policy. Changes to your driving schedule should be communicated at least 24 hours prior to your appointment. Any modifications requested after this timeframe, or failure to attend the appointment, will incur a fee of $30.00.