Fresh Green Light, LLC Registration

Registration

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

In order to register, you'll need the number of the enrolling student's Driver License or Permit and a credit card.

For legal reasons, only a parent or legal guardian can register a new student who is under the age of 18. 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:

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

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

Who is your mobile phone carrier?

Home Address:

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

City:

State/Province:

Zip/Postal Code:

Country:

What High School does the student attend?

Please tell us what high school the student attends:

Student currently has a

The Permit/License number is

State of issuance

What is the expiration date of your :

How did you find out about Fresh Green Light?

Please describe how you heard about us:

Parent or Legal Guardian information.

First Name:

Last Name:

Home Address:

City:

State:

Zip/Postal Code:

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email Address:

Who is your mobile phone carrier?

Terms and Conditions

•I certify that I am the parent or legal guardian of the student applicant and grant permission for him/her to enroll in the Fresh Green Light Driver Training Program.

•I understand the Fresh Green Light program may consist of behind-the-wheel instruction, simulation instruction, and five (5) hours of classroom instruction, supported by self-paced computer-based training.

•I understand that my child must bring his/her permit or driver license to every behind the wheel lesson. If he/she does not have his/her permit or driver license, I understand that he/she 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.

•My child 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:
• Student possesses a valid state driver license or learner permit.
• Student is not currently using any medications that induce drowsiness or otherwise cause impairment.
• Student does not suffer from any conditions (e.g., such as epilepsy or severe visual impairment), which would make participation in the program unreasonably dangerous.
• Student will not have used alcohol, or any recreational drugs in the 24 hours preceding his or her 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: