Fresh Green Light Online Enrollment

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Selected Teen Class - Price: $

Class Number	Start Date	End Date	Session Details	Location

Now select the two-hour class that you and your parent/guardian will attend. - Price: $

Selected Parent Class - Price: $

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Student Information

Student Type-if you are under 18, please select Teen. If you are 18 or older, please select Adult:

Parent Email 2:

First Name:

Gender:

Middle Name:

Wear Glasses/Contacts:

Last Name:

Drivers License or Permit#:

Address:

Permit/License#:

City:

State of Issuance:

State and Zip:

Drivers License or Permit Issue Date:

Date Of Birth:

Drivers License or Permit Expiration Date:

Student Email:

Temporary Permit Expiration Date

Cell Phone:

Do you have any medical conditions that we should be aware of:

Cell Phone Carrier:

How Did You Hear About Us:

Home Phone:

Who referred you? (First, Last Name):

Parent First Name:

High School:

Parent Last Name:

Does the student have ADD or ADHD?:

Parent Phone:

If answered yes to the question above,please state any medications they are on:

Parent Email 1:

Is your Teen involved in extracurricular activities (sports, work, etc.)?:

If answered yes to the question above, please state the day(s) that they are unavailable:

Special Instructions:

Payment Information

We Accept:

Billing First Name:

Credit Card Type:

Billing Last Name:

Card Number:

Billing Address:

Expiration:

Billing City:

Security Code (What is This?):

Billing State and Zip:

Payment Amount:

PLEASE ACKNOWLEDGE YOUR UNDERSTANDING AND AGREEMENT WITH THE FOLLOWING POLICIES: 1. LATE CANCELLATION POLICY WE confirm driving lessons with instructors 24-hours in advance of the lesson start time. A $50 fee will be incurred for any driving lesson cancelled with less than 24-hours’ notice (regardless of the reason for the cancellation.) 2. VIDEO CAMERAS IN TRAINING VEHICLES For the safety and security of our students and instructors, video cameras are active both inside and outside the vehicle during all in-car lessons. 3. 40 Hours of Practice Driving is required by the State of CT. Fresh Green Light will provide a minimum 8 hours of driving instruction and Parents/Guardians are responsible for at least 32 hours of additional practice driving hours with students.

REFUND POLICY: There will be NO refunds issued after 1 YEAR from enrollment date. Eligible refunds are subject to a $50 administrative fee.