Capital City Vineyard Church
Driver Education Training Registration

Student Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Birthdate*
Date Format: MM slash DD slash YYYY
Driver Education Classes at Capital City Vineyard Church*
Segment 1 Course Dates*
Segment 2 Course Dates*
Important: Students must hold their Level 1 license for at least 90 days and have completed 30 hours of driving, two of which are at night. Do not sign up for both Segment 1 and 2 classes unless they are at least 3 months apart.
Total
$0.00
Other Information
Note if the student has any medical, physical, learning, or disability condition here.
Payment*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name