Enroll - Step 1

Form for Online Course Only (DE101)
*Is a required field
Step 1

Prior to completing this form please read the following IMPORTANT instructions: Use this form if you intend on enrolling in the online driver education course now. If you are are a Driversity student this form is ONLY for students that reside in the vicinity of the Alameda or San Leandro Driversity of the East Bay locations. If you do not reside near these Driversity locations use the menu below to find the correct form and the correct course.

If your closest location is Antioch go here. If it is Concord go here. if it is Dublin go here.

*Student First and Last Name

* DOB: mm/dd/yyyy

*Address, City, Zip
, , CA

*Phone + Area Code

*Cell/Other + Area Code

* High School Student Attends :

* Student e-mail:

* Parent e-mail:

*Parent or Guardian Name

*Parent / Guardian Phone

Tuition for the course is $75. Determine how you would like to arrange tuition payment. Please note that you will have the opportunity to pay via PayPal on the next page. You will be able to gain instant access to the course.

*Method Of Payment:	*Enter Preferred method of payment

Please acknowledge that you have read and the following terms and conditions by entering your initials in the box below.
1	It is agreed that you are enrolling in a distance learning or online course.
2	You understand that the online version of this course is identical to the course that is taught live. However, you are aware that an online course requires more self-discipline than a live course.
3	You understand there is a 65-day maximum period from the date of enrollment to complete the course.
4	You understand that this course is not transferable into any other course.
5	You understand that should you choose not complete the course, a certificate cannot be issued.
6	You understand that refunds are not available once you begin the course.
You have read 1-6 above and agree by entering your initials here:

You have or are you planning to enroll into a Driversity location for for driver training? (yes, no, I don't know)
Select the Driversity location that is closest to you. Please note that this form is ONLY used for Driversity's of the East Bay's Alameda or San Leandro location students. If you need a different location go here to find the correct location.

By signing below you agree to abide by the rules set forth in the course. Please sign by typing in your name. Once you submit this form you will be routed to a page that contains the process for step two.

* Parent Signature

* Student Signature

Please submit the form once.