Lewis County Driving School
1009 Kresky Ave., Centralia, WA 98531  
360-330-0344 voice  360-330-5419 fax
www.LewisCountyDrivingSchool.com
Registration Form.
Student's Full Name:
Last: ________________________ First: _________________________ Middle: _________________
Street Address: ____________________________
City: ____________________________________
County: ______________________ Zip: ________		 Mailing Address: __________________________
City: ____________________________________
County: _______________________ Zip: _______
Student's Phone:
Home: _________________  cell: _____________
                                                    text: yes ___  no ___
Date of Birth: _____________________________
         (month / day / year) 		Parents' Phone:
Mom Work: ____________ Dad Work: __________

Mom cell: _____________  Dad cell: ____________
         text: yes ___  no ___          text: yes ___  no ___
Permit Number: _______________________  OR   Height: _______ Weight: ______ Eye Color: _______

Student must be at least 15 on first class day.  If a student does not have a permit upon enrollment and is paid in full, a waiver will be issued no more than 10 days before the first class session.  A waiver is required for a permit if the student is not yet 15 1/2 years old.  The student must have a permit at least 6 months, complete a driver's education course, and be at least 16 years old to obtain a intermediate driver's license.
Contact person: ____________________________
                                   (Other than parent or guardian)		 Relation to Student: _________________________
Phone: ___________________________________

Earliest Possible Start Date: _______________________           See all possible class days and times below.  The course schedule will be set at orientation meeting so all students will be able to attend all classes.  Students must attend all classes.  See web for class start dates and schedules.  
During school year - 7 week course
Possible Class Days:
      Mon/Wed   or   Tues/Thurs   or   Sat/Sun 
Possible Class Times during the week:
      3:30pm to 5:30pm   or   6pm to 8pm 
Possible Class Times on weekends:
      10 to 12 noon  or  2 to 4pm		 During Summer Only- 5 week course
Possible Class Days: 
       Tues/Wed/Thurs 
Possible Class Times:  
       10-12am   or   4-6pm   or   6-8pm 

Best Email Address: _____________________________________________
Parent / Guardian signature **; Please read parent information before signing.

Sign name: _______________________ Print name: __________________________ Date: ________
** Signature implies Parent / Guardian has read and understands this information and has read parent information page.
      It also implies Parent / Guardian gives permission for Lewis County Driving School to schedule drive lessons with the student.
*** Due to the nature of the course, the fee is not refundable after the first class session.
       Course is to be completed within 12 weeks to avoid being dropped from the course. 
The student will be dropped at 12 weeks if not completed.  If the student would like an additional five weeks to complete, an additional $125 fee is required.   Parent initial: _______

_______________________________________________________________________________
_______________________________________________________________________________
Office use only...
Paid $350.00 yes ___
cash ___ check ___ M/C-Visa ___ M.O. ___
Date:   ___________		 Waiver issued yes ____ no ___
Book #  ____________		 Start Date:  _________
End Date:   __________
Drop Date: __________