Teen Registration for PBDE Full Program and 2-Day Advanced Skills

Which Program Are You Registering For?*
- Performance Based Driver Education Program - Full Program
- 2-Day Advanced Skills (Included in full program)
Performance Based Driver Education Program: Full Program also includes the 2-Day Advanced Skills
Student's Name*
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY

mm/dd/yyyy
Both Parents in House?*
- Yes
- No
Student's Address*
Street Address City State ZIP Code
Student Cell*
Student's Email*
High School*
Does the student have any medical issues, or taking medication?*
Vision Correction?*
Any Vehicular Trauma?*
Mother's Name*
First Last
Mother's Employer and Position*
Mother's Phone Number*
Mother's Cell Phone Number*
Mother's Email*
Father's Name
First Last
Father's Employer and Position*
Father's Phone Number
Father's Cell Phone Number
Father's Email
Temporary Permit Number
Date Issued
MM slash DD slash YYYY
Car Make to be used for Skills Training*

(ex. Ford)
Car Model to be used for Skills Training*

(ex. Mustang)
Car Year to be used for Skills Training*
Auto Insurance Carrier for Student and Car to be used*

Online Payment
Please select the appropriate price category. Then submit registration to begin your online transaction with PayPal. *Fees will be deducted from any reimbursement.
Name on Credit Card
First Last
Customer Email
Performance Based Driver Education Program Quantity
Price: $895.00
Full Teen Driver Education Program
2-Day Advanced Skills Quantity
Price: $445.00
Enhancing performance for beginning and first-year drivers
Total
$0.00
Other Payment Options
- Pay By Check
In consideration of my attendance at or participation in a DriveTeam Akron LLC program or clinic:

1. I hereby knowingly and voluntarily waive forever any and all liability on the part of, and covenant not to sue or institute any legal claim against DriveTeam Akron LLC, its instructors, insurers, property owners, successors or assigns, or any sponsor, resulting from or arising out of or in connection with my attendance at or participation in a DriveTeam Akron LLC program or clinic.

2. I hereby knowingly and voluntarily assume full responsibility for the risk of bodily injury, death, or property damage incurred by me as a result of my actions, or of any accident, collision, act of God or act or failure to act of DriveTeam Akron LLC or of any sponsor, in connection with my attendance at or participation in a DriveTeam program or clinic.

3. This Waiver of Liability and Release shall be binding upon me and my personal representatives, assigns, heirs and next of kin.
Agreement*
- I agree with DriveTeam's Waiver of Liability & Release form
Name
This field is for validation purposes and should be left unchanged.

Teen Registration

TEEN Registration

Step 1 of 3

Please Pick Desired Skills Weekend

Online Payment

In consideration of my attendance at or participation in a DriveTeam Akron LLC program or clinic:

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