PRE-REGISTRATION

PLEASE PRINT WITH DARK INK

Student is registering into two (2) independent/home study Programs:

No refunds once submitted

1) Driver Education & 2) Drug and Alcohol Awareness

 Program 2 may be substituted  by PEN

STUDENT INFORMATION

Student's First Name

 

Middle Initial

 

Last Name

 

 Date of Birth

Month Day Year

Select One Course Type

Internet Mail 

 

 

    19

Address

Apt. No.

City State           Zip Code

Phone   (           )

Email Address

Student's School

Grade Level

List all Disabilities
The parent/guardian signing this application certifies, under penalty of perjury that:

1.  parent/guardian has custody of applicant named on this form and consents to the enrollment and participation of applicant  in Driver Education and Drug & Alcohol Awareness programs,

2.  parent/guardian will proctor and monitor exams to the applicant.  The applicant will take these exams personally and without assistance of any type (books, notes, person, etc.),

3.  I agree to all terms, rules and procedures that I have read on the Driver Education Home Study Information page.

4.  any or all information may be disclosed and/or tracked for studies and/or audits pertaining to the effectiveness and compliance of home schooling Driver Education.

5.  all statements made on this form are true and correct.

PARENT/GUARDIAN INFORMATION

FULL NAME

 

CHECK ONE

PARENT  

GUARDIAN   

CA LICENSE NUMBER

 

EXPIRATION DATE  

MONTH DAY YEAR

SIGNA- TURE

 

TODAY'S DATE  

MONTH DAY YEAR

IF PAYING BY CREDIT CARD SELECT ONE

VISA

MASTERCARD  

CARD NUMBER

NAME ON CARD

 

EXPIRATION DATE  

MONTH YEAR

my signature authorizes private educational network (a.k.a. penschool) to deduct a non-refundable $110 (ONE- HUNDRED TEN  dollars) from my credit card indicated above.  this payment is for tuition.  certification is contingent on student successfully passing the above courses.                                      

SIGNATURE

 

TODAY'S DATE  

MONTH DAY YEAR
FOR FASTER PROCESSING, PRE-REGISTRATION PAID BY CREDIT CARD MAY BE FAXED TO (408) 280-0109

MAIL THIS PRE-REGISTRATION WITH CREDIT CARD INFORMATION COMPLETED OR A $110 CHECK OR MONEY ORDER TO

PEN   408-280-1122
1020 Willow Street
San Jose, CA 95125