Driver Education Class Driving School Location*Driver Training Inc. Bristol, VASelect a Driving School LocationClass Date02/05/2018 - 02/28/201804/02/2018 - 04/25/201806/04/2018 - 06/27/201807/02/2018 - 07/30/201808/06/2018 - 08/29/201810/01/2018 - 10/24/201810/03/2017 - 10/26/201711/01/2017 - 11/29/201711/28/2018 - 12/31/201812/04/2017 - 01/03/2018Please select the course date you would like to enroll in above.Class Date for Driver Training Inc. Bristol, VA, 1061 Old Abingdon Highway, Suite 3, Black Wolf Plaza*10/03/2017 - 10/26/2017, Tues & Thurs 5-8:30 pm11/01/2017 - 11/29/2017, Mons & Weds 5-8:30 pm12/04/2017-01/03/2018, Mons & Weds 5-8:30 pm02/05/2018 - 02/28/2018, Mons & Weds 5-8:3004/02/2018 - 04/25/2018, Mons & Weds 5-8:3006/04/2018 - 06/27/2018, Mons & Weds 5-8:3007/02/2018 - 07/30/2018, Mons & Weds 5-8:3008/06/2018 - 08/29/2018, Mons & Weds 5-8:3010/01/2018 - 10/24/2018, Mons & Weds 5-8:3011/28/2018 - 12/31/2018, Mons & Weds 5-8:30Please select the course date you would like to enroll in above.Class Type*$375 - Classroom and Behind-the-Wheel Instruction (50-50 min. periods) - required for Virginia residents, 7 sessions of Behind-the-Wheel, and 7 sessions of observations$300 - Classroom Only (36-50 min. periods)$10 - Certificate replacementSpecial NeedsPlease select the course you would like to enroll in above. Any behind the wheel classes will be scheduled separately taking into consideration the parent's/student's schedule. A non-refundable application fee of $40.00 is included in the amounts and there will be no refunds after 60 days. Special Needs Pricing:* Payment Method*Pay by PayPal (You do not have to have a PayPal account), Visa, Master Card, AM EX, E-Check, etc...Pay by CashUnfortunately, we do not accept checks. Student InformationPlease enter "Full Legal Name"First Name*Middle NameLast Name*Date of Birth* MM DD YYYY Age*Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Phone Number*Student's Mobile PhoneHigh School (if applicable)GradeDoes the student have a learner's permit or driver's license?*YesNoPermit/License Number*Date Issued* MM DD YYYY Expiration Date* MM DD YYYY Parent/Legal Guardian Name (if under 18 years of age) Parent/Legal Guardian PhonePlease enter the Parent/Legal Guardian Phone: (###)###-####Parent/Legal Guardian Email Please answer the following questions.Has the student experienced a physical, mental, or visual illness, injury, or condition that may affect his/her ability to operate a motor vehicle?*YesNoHas the student experienced a blackout, seizure, loss of consciousness, or fainting?*YesNoDoes the student take any medication or drug that would impair his/her ability to drive?*YesNoHas the student's privilege to drive or eligibility to obtain a Virginia Instructional Permit or Drivers License been prohibited, suspended, or revoked by any court or the Department of Motor Vehicles?*YesNoHas the student experienced any reading or learning disabilities?*YesNoIs the student color blind?*YesNoIs the student working on the 45 hours of practice driving with 15 hours being after sunset?*YesNoHas the student experienced any signs of anxiety or is he/she overly fearful of driving or taking this course?*YesNoMaking the instructor aware of anxiety, fear, or special needs, will enable the instructor the ability to work more effectively with the student.Does the student have any other social needs?*YesNoIf so, please explain below.Comments TERMS OF AGREEMENT AND DRIVING SCHOOL RULESTERMS OF AGREEMENTThe student/parent/legal guardian agrees to pay all the costs of instruction prior to the beginning of the course. Fees are subject to change without notice. This agreement constitutes the entire agreement between the student/parent/legal guardian. I have read, understood, and agree to fully comply with all parts of this agreement. The undersigned parties certify that all information given in this application is true to the best of their knowledge, and agree to abide by all driving school rules listed. INSTRUCTIONAL AGREEMENT DTI was founded to teach the latest defensive driving techniques and to enhance driver awareness of risks faced while driving. DTI is dedicated to a quality educational program. In keeping with DTI's educational principles, DTI assures the following: · The course curriculum will be presented by instructors licensed by their respective state. · The Driver Education Program is state approved and meets or exceeds standards set by the Department of Education. · Textbooks and course materials are provided. The vehicle is equipped with seat belts, rear view mirrors, safety equipment, rooftop and rear display signs. · The classroom and in-car instruction does not guarantee that any student will pass the state license examination or be guaranteed employment. STUDENT AGREEMENT The student certifies that all information contained in this application for instruction is true and accurate to the best of his/her knowledge, and that this agreement is a request for the student’s enrollment in the course selected. The student fully understands and agrees that attending this course of instruction does not constitute successful completion, nor does it guarantee that any student will gain a State Driver's license. The student agrees that in the event of a medical emergency, any instructor or agents of DTI may authorize medical treatment by a proper medical facility, hospital, physician, if the student is physically unable to authorize medical treatment for him/herself if over eighteen (18) years of age. The student fully understands and agrees that no student is to be in a DTI car with the motor running or with the keys in the ignition switch unless accompanied by a certified DTI instructor. If an accident were to occur while driving, the student and or parent will be responsible for the deductible of the Driver Training Inc. insurance policy. An estimate of the damage will be provided by Driver Training Inc. from a reputable car dealer or repair shop approved by the insurance company and Driver Training Inc.. The student’s license will be withheld until all issues are resolved. The student fully understands and agrees that successful completion of the DTI behind-the-wheel course does not imply that the student is an accomplished driver. NHTSA is committed to promoting transportation safety through the certification of quality driver training programs. If you have comments or concerns about this course, call our toll-free number: 1-888-327-4236There's a lot of important information here. Please scroll to the end to continue.TERMS OF AGREEMENT* I have read and agree to the Terms of Agreement (You must scroll through the TOA) DRIVING SCHOOL RULESDTI has certain rules of conduct that the Student hereby agrees to abide by at all times. Failure to comply with the rules may result in suspension from the program with no refund of fees paid. The following is a list of DTI rules. 1. Noise. An atmosphere conducive to learning must be maintained for the benefit of all students. Loud talking, noise, and other disruptions are not allowed. Distracting objects (e.g. cell phones, games, etc.) may be confiscated and held until the end of class. Cell phones and pagers must be turned off during class, or confiscated. 2. Damage and Trash. Students must not damage equipment, tables, chairs, desks, or other DTI property. Students must dispose of all drink cans, snack wrappers, and other trash in appropriate locations. 3. Personal items. Students should take care to collect all personal items before leaving class. DTI is not responsible for any personal items that are lost if left on DTI property. 4. Drugs/ Alcohol. For the safety of everyone concerned, any student suspected of using drugs or alcohol will not be allowed to drive. If a student under the age of 18 years old is suspected of using drugs or alcohol, his/her parents will be notified. 5. Smoking. Please do not smoke on DTI property. If any student under the age of 18 years old is caught smoking on school property, his/her parents will be notified. 6. The student/parent/legal guardian understands that any intentional dangerous acts in the nature of horseplay, pranks, class disruption, willful misconduct, or willful damage to school property are grounds for expulsion, without refund of fees. Student/parent/legal guardian understand that they will be held responsible for the cost of replacement should any damage arise to school property by violating any of the rules above. 7. We understand that sometimes absences are unavoidable. All classroom classes missed will need to be made up. Everyone has to attend all classes. 8. When arriving for behind-the-wheel lessons, please do not wear the following shoes: · Flip Flops or Heavy Work Boots. 9. If you are going to be late for an in-car lesson (outside of business hours), please call the following number: 276-644-1845. If you do not call 24 hours prior to the lesson regarding a cancellation, there will be an additional change to make the lesson. 10. All absences, whether classroom or in-car will be made up in the proper sequence of events. * Additional charges apply for use of school vehicle in taking a driving test to obtain a driver's license from the DMV. * Additional charges apply for door to door pick-up. * A refund of any fees or tuition or any part of fees or tuition will be provided upon request if DTI is unable or unwilling to perform its part of the contract within a reasonable time period. * A non-refundable application fee of $40.00 is included in the above amounts. * Additional tutoring is available if needed at $40.00/hour.There's a lot of important information here. Please scroll to the end to continue.DRIVING SCHOOL RULES* I have read and agree to the Driving School Rules (You must scroll through the DSR) Keep up with the latest laws Yes, I would like to receive news and information via email Confirmation Email* A CONFIRMATION EMAIL WILL BE SENT TO THE STUDENT’S EMAIL ADDRESS PROVIDED DURING REGISTRATION. PARENTS, PLEASE CHECK WITH YOUR STUDENT FOR FURTHER INFORMATION.