Driving Lessons

BLUEPRINT EDUCATION Enrollment Form

Please note: A Driver's Ed representative will contact you within 2 business days from receipt of this enrollment form.

Student's Name * First Last

Gender * Male Female

Birthdate * / MM / DD YYYY

Do you have any physical/mental conditions which may interfere with your ability to drive? * Yes No

If you answered "yes" to the question above, please explain...

Student Permit # *

Student Permit Expiration Date * / MM / DD YYYY

Did you complete the online course to obtain your permit? * YES NO

High School of Attendance *

Student Contact Information

Home Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Mailing Address (if different from home address)
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

General/Home Phone * - (###) - ### ####

Student's Cell Phone - (###) - ### ####

Student's E-mail Address *

Parent Contact Information

Parent 1 * First Last

Mother Father

Parent 1 Cell Phone * - (###) - ### ####

Email *

Parent 2 First Last

Mother Father

Parent 2 Cell Phone - (###) - ### ####

Email

Referral Information

Who referred you to our Driver's Education/Driving Lessons program? *

If you chose other in the previous question....please specify who referred you below

Insurance Information (Please provide for potential discounts from your insurance company)

Insurance Company *

Insurance Agent First Last

Phone Number - (###) - ### ####

Driving Lesson Payment & Option Information

Please pick your driving lesson option * ($330) 6 hours driving instruction ($400) 8 hours driving instruction (NO EXPERIENCE)

Driving Evaluation information * Please note that driving evaluation time can be applied to a 6 or 8 hour driving lesson option. Driving evaluations by themselves will not constitute the completion of a driving lesson program.

Please pick your driving evaluation option * I am signing up for driving lessons and do not want/require an evaluation ($65) 1 hour driving evaluation ($180) 3 hours driving evaluation

Please indicate how you would like to pay for the driving lessons/MVD certificate. We accept credit and debit cards, check and money order payments. *

If paying by check or money order please be sure to include the student's name with payment. Thank you!

Payment can be made over the phone by calling 1-800-426-4952 (ask to speak with a Driver's Ed Representative). Payment can also be mailed to: Blueprint Education ATT: DED Registration 5651 W. Talavi Blvd. Suite 170 Glendale, AZ 85306

© 2008 Blueprint Education