Fresh Green Light, LLC Registration

Registration

Thanks, we're excited you've chosen Fresh Green Light!

In order to register, you'll need your Driver License or Permit and a credit card. All the information you provide is strictly confidential and will not be shared with anyone other than you.

Note: Items highlighted * are required.

Student's First Name:

Student's Middle Name/Initial:

Student's Last Name:

Birth Date: (mm-dd-yyyy)

Gender:

Email Address:

Cell Phone: (###-###-####)

Home Phone: (###-###-####)

Home Address:

(This should be the designated home address for Behind-The-Wheel Lesson pick up and drop off)

City:

State/Province:

Zip/Postal Code:

Country:

Who is your mobile phone carrier?

I currently have a

My Permit/License number is

State of issuance

What is the expiration date of your Permit/License:

How did you find out about Fresh Green Light?

Please describe how you heard about us:

Terms and Conditions

• I understand that I must bring my Driver License or Permit to every behind the wheel lesson. If I do not have my Driver License or Permit, I understand that I will need to forfeit the lesson and make it up another time.
• I understand and accept that any in-car or simulator lessons that are forfeited or cancelled with less than 24 hours notice will incur a $50.00 cancellation fee, and I give my permission to have that fee automatically charged to my credit card on file.
• I will follow the Fresh Green Light Code of Conduct at all times.
	
	
	WAIVER, RELEASE AND INDEMNITY AGREEMENT

I understand that Fresh Green Light, LLC will conduct an educational driving program (the “Program”) for students with a valid driver license or learner permit. I further understand that, as part of the Program, the student, accompanied by a NY-certified driving instructor, will drive a motor vehicle equipped with an instructor-accessible brake (per the requirements of the State of New York) in parking lots, streets and highways.

I represent and affirm that all of the following statements are true and correct:
• I possess a valid state driver license or learner permit.
• I am not currently using any medications that induce drowsiness or otherwise cause impairment.
• I do not suffer from any conditions (e.g., such as epilepsy or severe visual impairment), which would make participation in the program unreasonably dangerous.
• I will not have used alcohol, or any recreational drugs in the 24 hours preceding my participation in the program.

I will not reproduce any course content or testing materials in any way without prior written permission from Fresh Green Light, LLC and/or its various partners. Furthermore, I will not give, copy or otherwise distribute any of the course materials to anyone without prior written permission from Fresh Green Light, LLC.

I have read and understand each of the provisions of this Agreement. I agree that no statements contrary to anything contained in this Agreement have been made to me by Fresh Green Light, LLC or its agents or affiliates. I am executing this Agreement freely and voluntarily and without reliance upon any verbal representations or inducements other than the consideration described above.

I certify that I have read, understand and accept all of the responsibilities and obligations outlined above: