Programs *

Please select ONLY one program.

Program 1: June 3 - June 7 (8:00 a.m. - 12:00 p.m.)

Program 2: June 24 - June 28 (1:00 p.m. - 5:00 p.m.)

Name of Student *

First Name

Last Name

Student Contact Number *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Student Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/ Legal Guardian Name *

First Name

Last Name

Parent/ Legal Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/ Legal Guardian Contact Number *

(###)

###

####

Emergency Contact Name Other Than Parent *

First Name

Last Name

Emergency Contact Other Than Parent Phone *

(###)

###

####

How did you hear about the event?

News Article

Friend-Relative

Social Media

TV

Other

Payment Option *

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 AND THOSE OF YOUR STUDENT. IF YOU DO NOT UNDERSTAND THIS DOCUMENT, YOU SHOULD CONSULT WITH AN ATTORNEY BEFORE SIGNING. Indemnification and Hold Harmless: PARENT agrees for PARENT and STUDENT, 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 PARENTS, STUDENT, 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, PARENT gives permission for STUDENT to participate in a Drivers' Education program ("PROGRAM") being offered by the St. Joseph Safety and Health Council, Inc. ("SAFETY COUNCIL"). PARENT 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 gaurdian(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.