Registration Form: Mentoring, Test Prep, Lessons, MVA Test

Personal Information
First Name:
Middle Name
Last Name:
Address:
Address 2:
City:
State:
Zip:
Phone Number: xxx xxx xxxx
Email Address:
Re-enter Email Address:
Learner's Permit Number:
Learner's Permit Expires:
Date of Birth: mm/dd/yyyy

Course Information
Student is registering for:

MENTORING PACKAGE (can purchase as many packages as needed)

$499.99 --10 Hour package EMDS Certificate #:

$320.00 --6 Hour package

$ 169.99 --3 Hour package

$129.95 --One Test at the M.V.A. to obtain a Driver's License. Must be a former student of EMDS. EMDS Certificate #:

$149.99 --One Test at the M.V.A. to obtain a Driver's License. Non-EMDS driver education student

OTHER

$92.99 --Per 1.5 hour lesson.

$399.99 --Virginia Teens Only-36 hours classroom and 7 periods of driving and 7 periods of observation and tes


Payment Information
Cost Total: $
Charge Type: VISA
MASTERCARD
DISCOVER
AMERICAN EXPRESS
Card Number:
Expiration Date: (MM/YYYY)
Cardholder Name
CVV2 For AMERICAN EXPRESS enter the 4 numbers on the front top right corner. For all other cards, please enter the last 3 numbers on the back side of your card.

Policies

By initialing below, I agree to the following EASY METHOD DRIVING SCHOOL policies:

*All fees are due at time of service

*When paying by check for packages or test, payments must be received in office and cleared by bank prior to starting lessons or taking test

*Through it tries not to change/cancel scheduled appointments, there are times when it is necessary to do so. Therefore, EMDS reserves the right to change/cancel driving appointment

*Student is required to provide at least 24 hours notice to cancel/change appointment



*Excessive failure of student to give notice of canceling appointments may result in student's account being charged for lesson. (EMDS will notify student that charge will occur before doing so)

** Once a student starts a mentoring plan, no refunds will be given.

***If a refund is applicable, refunds will be issued 30 days from date of request.

*Refunds: EASY METHOD DRIVING SCHOOL offers no refunds for this course.

I agree: Student's Initials,  Parent / Guardian Initials (for under 18 student)