Driversity East Bay - Enrollment Form

Please note: This form is for the Driversity of the East Bay ONLY.

For the Antioch or Concord locations go here. For the Dublin locations go here.

*Is a required field

Student Section
* Student's True Full Name (first, middle and last name)	* Address	* DOB: mm/dd/yy
City , CA Zip	* Phone:	*Cell Phone:
* Student e-mail:	* High School Student Attends :
Parent Section
* Parent or Guardian First and Last Name:	* Phone:	* Cell Phone:
* Parent e-mail :	Additional Info (optional)

Enter your student status. Are you a former, current, or new Driversity East Bay or Kirk Enterprise High student. Enter former, current or new ------------------->	*Student Status:
Enter the course you are enrolling or are enrolled in. Use the select field below. Select and enter in this box ---------->	*Course:
If your enrollment is in driver training (you have your permit), please enter your permit number in the box provided. If you don't have a permit enter none. ------->	*Permit Number:
If a charge is involved indicate how you would like to pay the service. Select and enter in this box --------------->	*Method of Payment :
Who is completing this form? (Parent, Student, etc.)*

Please acknowledge that you have read and the following terms and conditions by entering your initials in the box below.

1.	It is agreed that you are enrolling into a Driversity East Bay course.
2.	It is agreed that a non refundable administrative enrollment fee of $95 or $110 (Driver Ed with us) or $115 (Driver Ed elsewhere) for enrollment will be charged when the driver training enrollment certificate is issued.
3.	It is agreed that when a certificate is issued the $95, $110, or $115 fee must be paid before the certificate will be sent to you. You may pick the certificate up from the San Leandro office however, you must request this and pay the $95, $110, or $115 fee when the certificate is issued.
4.	You understand that once the certificate is issued the fee is not refundable for any reason.
5.	For the driver training course, you acknowledge that you are within the range of the San Leandro location. If you are not see the note above at the top of this form.
6.	You have read the 1-5 above.
Enter Initials here:

Please sign by typing in your name.

* Parent Signature

* Student Signature