Phoenix - Registration Form

Thank you for deciding to register for our life saving
Car Control & Collision Avoidance driving clinic.
Please remember:

PAYMENTS ARE NON REFUNDABLE. You may apply any balance on account towards another clinic date at no cost to you as long as you provide us with at least 7 days notice. If you cancel inside of 7 days or no show for your clinic, a $50 late cancel fee will be assessed against your balance on account.

  1. A parent or guardian must sign the Minor Consent Form and Minor Liability Waiver forms if you are under 18 years of age. For participants 18 years of age or older please complete the Adult Liability Waiver Form.
  2. You must bring a valid, state or federally issued photo I.D. with you (drivers license, etc.).
  3. You must pre-pay for your clinic:
  4. Once you fill out this registration form, please click the "Continue" button at the bottom of the form to be redirected to our PayPal payment page.
  5. Once your payment is successfully processed a receipt email will be sent to you along with a separate email confirming your registration.
  6. Your clinic registration confirmation email may end up in your "SPAM" folder so be sure and check for your confirmation there too. Your clinic registration confirmatione.
    NOTE: Failure to show up without providing at least 7 days notice will result in a $50 "No Show" penalty being assessed against your non refundable payment. There is NO fee for rescheduling outside of 7 days.

    We look forward to seeing you!

  Registration Form

* Required Fields
Program Date: * Please only choose one program date.
First Name: *
Last Name: *
Age:
Date of birth (mm/dd/yyyy):* / /
High School Currently Attending?
Do you have a valid drivers license?* YesNo
Currently Suspended License
Parent Email Address: (if under 18 years old)
AOL users may have difficulty receiving confirmation emails due to tight SPAM security measures.
Student Email Address:*
AOL users may have difficulty receiving confirmation emails due to tight SPAM security measures.
Phone Number:* ()- -
Address: *
Address 2:
City:*
State: *
Zip Code:*
Court Appointed:* Yes No
Court Case Number:
Describe your infraction:
Are there any other teenage drivers in your family? Yes No
Promotional code (if applicable): Cactus Shadows HS use code CSHSBC
Comments

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