Student Registration

You have selected product January 9-24 @ 6-9 P.M. (Online Classroom + BTW at Alexandria Location) - $495.00.

Please complete the form below to set up your account for Central Lakes Driving School.

Contact / General Info

Driving History

Parent/Guardian Info

Payment / Terms

First Name

Middle Name

Last Name

Date of Birth

Gender

Time Zone

High School

Student Email

Confirm Email

Phone

Phone Type

Alternate Phone

Alt. Phone Type

Address

Address Line 2

City

State

Zip

How did you hear about us?

Do you wear glasses or contacts?

Is there anything else we should be aware of? For example, do you have any special notes for your driving instructor?

Have you ever held a driver's license or permit?

Driver's License Number

Permit Number

Parent/Guardian information is required for students under 18.

Parent/Guardian First

Parent/Guardian Last

Parent/Guardian Email

Parent/Guardian Phone

Parent/Guardian Phone Type

Parent/Guardian Alternate Phone

Parent/Guardian Alternate Phone Type

My parent's/guardian's address is the same as my address.

Parent/Guardian Address

Parent/Guardian Address Line 2

Parent/Guardian City

Parent/Guardian State

Parent/Guardian Zip

If you have a promo code, enter it below and press Apply

Promo successfully applied.

Product Price: $495.00

Total Charge:

How would you like to pay?

Cardholder Name

Card Number

Expiration Month/Year

Security Code

I agree with the Terms of Use and Privacy Policy

I agree with the Terms of Service Agreement

This constitutes the entire agreement between the school and the customer or student and no verbal statements or promises will be recognized.

Signature

Type Signature

Student Registration

You have selected product January 9-24 @ 6-9 P.M. (Online Classroom + BTW at Alexandria Location) - $495.00.

Product Price: $495.00

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