Education Classroom Registration Form
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1Victoria Educational Associates
_____________________________________________________________________________________________
Tina Garner - Director
Office: 361-573-2317
2701 N. Azalea, #15
Victoria, Texas 77901
TEEN 32 HR DRIVER EDUCATION CLASSROOM REGISTRATION
Total Classroom Fee is $199.00. To Officially Register for 32-Hour Classroom Instruction,
Mail, Call (Credit Card) or Bring This Form to Our Office with a $99.00 Check, Cash or Credit Card.
The $100.00 Balance Is Not Collected Until the Last Two Weeks of the Course.
Date: _________________
Type of Registration? (Circle one) In-person
Phone
Mail
STUDENT’S Name -
Print: ____________________________________________________________
Last
First
Middle
DOB: __________________
Circle one: Male or Female
Parent’s or Guardian’s Name (
) _________________________________________________________
Print
Parent’s Mailing Address: _________________________________________________________________
Street
City
Zip
Parent or Student e-mail: __________________________________________________________________
Mom Cell Phone ______________
Dad Cell Phone________________ Student Cell Phone _________
Mom Work Phone______________ Dad Work Phone ______________ Home Phone ______________
How much are you paying today? ____________
Circle one: (cash) (check) (credit card) (debit card)
If paying with a check, Check #_________
st
nd
Yes) (No)
Credit Card? (
): Visa, MasterCard, Am. Express - Run 1
and 2
payments on this card? (
Circle One
Card Number: _____________________________________
Expiration Date: ___________________
****CLASS: Date and Time you prefer ________________________________________________*****
Any absences must be made up to meet state requirements.
The fee to make up each 2 hour lesson will be $12.
__________
(Please Initial)
Does your child have any special learning needs or disabilities such as Dyslexia, Hyperactivity, vision or hearing problems?
Please Describe: _________________________________________________________________________________________
We now offer two options for completing the In-Car driving
Option 1: Your student will drive with our professional licensed In-Car driving instructors. This option
would require an additional fee to us AND an online scheduling website fee ($15), however we will
provide ALL paperwork the student will need and provide an in-depth foundation for your child to
become an experienced, safe and confident driver. The student would be able to drive for a total of 7
hours and observe for 7 hours & receive a certificate upon completion. (
_________
Please Initial
)
Option 2: You will have to order/purchase a Parent Taught Driver Education Packet from the TDLR
website to complete the 44 hours of In-Car instruction. ADDITIONALLY, you will need to
order/purchase a TDLR approved In-Car curriculum to teach the 44 In-Car hours. You will be
responsible for reading and teaching all information given in both packets including correctly completing
all paperwork.
________
(
)
Please Initial
PARENT/GUARDIAN SIGNATURE ________________________________________________________
Where did you hear about our school? TV, Friend, Paper ________________________________________
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