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Package Name	Package Description	Price	Select
Teen Program classroom only	Complete in-class instruction Obtain instruction permit after the fourth classroom session Licensed professional instructors Certificate of completion after last day of class View Schedule Alive @25 defensive driving course ($100 value) Does not include behind-the-wheel instruction	$200.00

Student Information
First Name:	*	Gender:	*
Middle Name:		High School(Teen Only):
Last Name:	*	Drivers License/Permit Number:
Address:	*	Drivers License/Permit Issued Date:
City:	*	Drivers License/Pemit Expiration Date:
State and Zip:	*	Parent/Guardian Name 1 (Teen Only):
Date Of Birth:	*	Parent/Guardian Phone 1 (Teen Only):
Student Email:	*	Parent/Guardian Email 1 (Teen Only):
Home Phone:		Parent/Guardian Name 2 (Teen Only):
Student Cell Phone:	*	Parent/Guardian Phone 2 (Teen Only):
Wear Glasses/Contacts:		Parent/Guardian Email 2 (Teen Only):
How Did You Hear About Us:	*	Do you have a discount coupon?Enter code:
Apartment #

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