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: _______________________________________  

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 or prior to the orientation meeting so all students will be able to attend all classes. Students must attend all classes.  See web or call for class start dates.  
5 week course
Class Days:       T/W/Th
Class Times:      3:30pm to 5:30pm   or   6pm to 8pm 

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

Parent signature: ______________________________ Print name: _________________________ 
Date: _______  

** Signature implies Parent / Guardian has read and understands this information and has read parent information page on back.
      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: _______   Student initial ________

_______________________________________________________________________________
_______________________________________________________________________________
Office use only...

Paid $ ______
cash ___ check ___ M/C-Visa ___ 
Date:   ___________
Waiver issued yes ____ no ___
Book #  ____________
Start Date:  _________
End Date:   __________
Drop Date: __________