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Drivers Education

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Segment I

Segment 1

Field name	Field
Personal Information
Full Name
Address	Address, line 1  Address, line 2    City/State/Zip
DOB
Sex:	Male  Female
Does your child have any physical/medical disabilities?	Yes  No
If you replied "yes", please explain.
Parent/Guardian Name
Home Phone	(Area code) Exchange - Number ext.
Cell Phone	(Area code) Exchange - Number ext.
Class Month	Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Class Time	12-2pm (June, July, Aug only) 6pm-8pm (excluding Aug)
E-Mail Address
Payment Info
We do not accept credit card payments. To make a payment you may send us a check or stop in our office with a check or cash.

Note: Your information will be encrypted with SSL when sent