First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code:
State:
TN
Daytime Phone:
Evening Phone:
Email:
(Student) High School Name::
Drivers License/Permit Number::
Date of Birth:
Which Course Do You Want To Attend? (DATE):
In Case of Emergency, notify::
Emergency Contact Number (Mobile):
Emergency Contact Number (Home):
PARENT/GUARDIAN INFO
if student is under 18 yrs of age
(Parent/Guardian) First Name::
(Parent/Guardian) Last Name::
(Parent/Guardian) Address:
(Parent/Guardian) City:
(Parent/Guardian) ST:
(Parent/Guardian) Email Address:
Any Known Allergies of Student:
Premium Lesson Package (30hrs classroom/6hrs BTW) $425.00:
Additional BTW Hour Sessions @ $50/hr TOTAL COST:
TOTAL PAYMENT:
I HAVE READ AND AGREE TO ALL THE TERMS AND CONDITIONS
