, Price: $
	Data Port 34 Hours Class, Price: $
	Total Price: $
	Referral Discount:

	Date Of Birth: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec    Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
	Location:
	Select DOB: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018   *
	No Classroom Available

	Class Number Start Date End Date Session Details Location       View/Print         View/Print

	Why add a Drive Fit to your Teen’s Driver Education Program? The Drive Fit Program is a 3-hour behind the wheel program on a closed course. Drivers use their own vehicles so they can learn how the vehicle they drive most often responds under emergency braking and quick steering maneuvers while also demonstrating the dangers of distracted driving such as texting. Students complete their new driver training course prior to taking the Drive Fit Program. Cost of the program is $0.00. Do you want to add Drive Fit?
	No Drive Fit Classroom Available
	Select Drive Fit Date:

	Student Information Student First Name:  * Student Email:  * Why we are asking for this? Student Middle Name:   Home Phone: Student Last Name:  *   Student Cell:  * Address:  * How did you hear about us?: -- Select -- Building Family/Friend Google Internet Search Postcard Saw our Hummer Saw our instruction car Yelp  * City:  * Gender: -- Select -- Male Female  * State and Zip: -- Select -- AK AL AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW QB RI SC SD TN TX UT VA VI VT WA WI WV WY    * Permit or Confirmation #: What is this? Date Of Birth: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018  * Permit or Confirmation Issued Date:       Parent/Guardian Name:    * Permit or Confirmation Expiration Date:     Parent/Guardian Cell #    * Do you have any medical conditions that we should be aware of?  -- Select -- Yes No   * Parent/Guardian Email:    * Medical Condition Explanation: High School: -- Select -- Adult Ballard Bishop Blanchet Eastside Catholic Garfield Hazen Holy Names Home School Ingraham Issaquah Kings Lakeside Liberty Mt Si Nathan Hale Northwest School Not Listed Nova ODea Roosevelt Seattle academy Seattle Prep Shorecrest Shorewood Skyline Sultan Tahoma High Two Rivers  *     Do you have a Referral code? Enter code:    Wear Glasses/Contacts: -- Select -- Yes No Coupon Code:      Special Needs:         Friend Referral Name:
	In order to enroll and confirm your seat in the class, a $100 deposit is required at the time of enrollment. To make this payment or to pay the package in full, please select the “Pay Now” option and select the amount you would like to pay from the “Payment Amount” drop down menu
I have read and agree to Shield Driving Academy's Policies and Procedures. I have read and agree to Shield Driving School's Policies and Procedures.
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	Payment Information                        We Accept: Billing First Name: * Credit Card Type: -- Select -- Master Card Visa * Billing Last Name: * Card Number: * Billing Address: * Expiration: Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052 2053 2054 2055 2056 2057 2058 2059 2060 2061 2062 2063 2064 2065 2066 2067 2068 2069 * Billing City: * Security Code (What is This?): * Billing State and Zip: -- Select -- AK AL AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW QB RI SC SD TN TX UT VA VI VT WA WI WV WY * Payment Amount: