Welcome Roanoke City Public Schools Let's get started!You must fill out the required (indicated with * ) form fields accurately and agree to the terms in this contract below. Once Drive This Way receives your application, a representative will get in touch with you to setup your final schedule. IMPORTANT! You must have your learner's permit! We will ask for your permit information below.Pick A Class Option BelowThe client/parent/legal guardian agrees to pay all costs of instruction prior to the beginning of the course. You may pay a deposit by credit card on this form today. We only accept cash, money order, or cashier check for all final or full payments of this course. (Note: The fees set herein are subject to change without notice.) Additional tutoring is available for $45.00 an hour. Please call the office for any questions concerning private one-on-one lessons.RCPS Behind-the-Wheel Training*DMV directed. 7- 50 minute sessions of driving and 7- 50 minute sessions of observation. Our vehicles are equipped with safety equipment recommended by the American Driver and Traffic Safety Education Association and Driving School Association of the Americas for all behind the wheel driver training. We adhere to all requirements to assure each student receives the most up to date driving techniques. IMPORTANT! If you choose to pay a deposit today, a final payment of $57.50 must be made by the first day of training. Final payments must be made with cash, money order, or cashier check. No personal checks accepted. IMPORTANT! If you choose to pay full price we must receive your payment before we can setup your schedule.$50.00 - Behind-the-Wheel Training - DEPOSIT$125.00 - Behind-the-Wheel Training - FULL PAYMENTHow do you wish to pay?*Important! We must receive a payment (either deposit or full price) before we can schedule your training.We accept cash, money orders, or cashier checks. Payable to:Drive This Way Driver Training8202 Williamson Road Roanoke, VA 24019I will pay deposit today with credit or debit card.You will be re-directed to PayPal to complete payment after you submit your form.I will pay full price today with credit or debit card.You will be re-directed to PayPal to complete payment after you submit your form.I will mail in payment.I will drop off payment.ERRORYou chose to pay a deposit with credit or debit card, but selected full payment under training options! Please fix your training and payment options in order to pay.ERRORYou chose to pay a full price with credit or debit card, but selected deposit under training options! Please fix your training and payment options in order to pay.Total Amount Due TodayThis is the total amount due today. If you chose to pay a deposit you may do so with a credit card. All final and full payments must be paid with cash, money order, or cashier check. *Payment is required before scheduling.* $0.00 Student InformationFill out the driving student information below.Student Name*Provide your full name below. Add NM in the Middle Field if you do not have a middle name. First Name Full Middle Name Last Name Date of Birth* Date Format: MM slash DD slash YYYY High School Name*Student ID*Numbers onlyHave you already completed a classroom or online driving class?*If you are signing up to take behind the wheel only we will need your class completion date below.YesNoSchool or Online Class Completion Date*The date you have received your School completion certificate in hand. Date Format: MM slash DD slash YYYY IMPORTANT! Learner's Permit Number*You must have a Learner's Permit if you plan to start behind the wheel training! Go to the VA DMV to learn more.Permit Issue Date* Date Format: MM slash DD slash YYYY Student Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Has student experienced a physical, mental, or visual illness, injury, or condition that may affect the student’s ability to operate a motor vehicle during instruction, routine, or heavy traffic conditions?*YesNoHas student experienced a blackout, seizure, loss of consciousness, or syncope?*YesNoDoes student take any medications/drug prescribed a physician or otherwise on a regular basis that would impair his/her ability to drive?*YesNoIs the student’s privilege to drive or eligibility to obtain a Virginia instructional permit or driver’s license prohibited, suspended, or revoked by any court or the Department of Motor Vehicles?*YesNoIs the student’s privilege to drive or eligibility to obtain a Virginia instructional permit or driver’s license prohibited, suspended, or revoked by any court or the Department of Motor Vehicles?*YesNoHas student experienced any reading or learning disability?*YesNoHas student-experienced signs of anxiety or is overly fearful of driving or taking this course? Or, does student have any other special needs? Note: Making the instructor aware of anxiety, fear, or special needs will enable instructor to work more effectively with the student.*YesNoHas student completed the required 45 hours of practice driving with 15 hours being after sunset?*IMPORTANT! If your answer is no, please finish filling out the form, but do give us a call at 540-761-5099 before trying to schedule lessons.YesNoIf not, how many hours of practice time have been logged?IMPORTANT! Please finish filling out the form, but do give us a call at 540-761-5099 before trying to schedule lessons.Contact InformationIMPORTANT! If you are filling out this form for someone under 18 please provide the parent or guardian contact information below.Parent or Guardian Name First Name Last Name Parent or Guardian Home AddressIf different from student address. Same as Student Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Mobile Phone*Student Contact Number (if different)Email*Provide an email to send payment confirmation, driving schedules, and instructor communication. Enter Email Confirm Email What is the best way Drive This Way can reach you with questions or schedule alerts?*What is your preferred method of communication? We may need to reach you right away with any changes to schedules or instructors, or weather related closings. Check all that apply. Call my Home Phone Call my Mobile Phone I am always on Email I will allow Drive This Way to Text my mobile phone. Terms & ConditionsThis is a binding contract. Please read our following terms and conditions. You must agree and sign this form to start your class.Driver Training Terms and ConditionsDrive This Way Driver Training was founded to teach the latest defensive driving techniques and to enhance driver awareness of risks faced while driving. We are dedicated to a quality educational program and making Virginia a safer place to drive. Instructors licensed by the Virginia Department of Motor Vehicles present the course curriculum. The Driver Education Program is state-approved and meets or exceeds standards set by the Virginia Department of Education and the Virginia Department of Motor Vehicles. Course materials, vehicle with a brake pedal on the right side for the instructor’s use, and restraint systems, extra rear view mirrors, rooftop and rear signs are provided. The client certifies that all information contained in the application for instruction is true and accurate to the best of their knowledge. The client fully understands and agrees that attending the course of instruction does not constitute successful completion nor does it guarantee any client a Virginia State Driver’s License. All academic standards and licensing requirements must be met as set by the Virginia Department of Education and the Virginia Department of Motor Vehicles to successfully complete the course and/or obtain a Virginia Driver’s License. Classroom Instruction: Students under the age of 18 are required to successfully complete a minimum of 36-hours of classroom instruction prior to receiving their temporary driver’s license. If the required classroom instruction was done through another training school, public school, or private online program; you must provide us with the original signed Certificate of Completion before starting the behind the wheel instruction. Drive this Way offers an online class that satisfies the classroom requirement. If you are registered in our online class, you may start the behind the wheel instruction (providing you have the required 45-hours driving experience) immediately. However, the online class must be completed prior to receiving the temporary license. For the online classroom training only, there will be no refunds after 60 days of registration. Refunds before the 60 days are determined case by case. Please review the online class procedures here: https://drivethiswaydt.com/online-classroom/. Behind-the-Wheel Instruction: Students under the age of 17 are required to have 7/7 50-minute sessions of driving. This consists of seven periods of driving and seven periods of observation with a certified, DMV- approved instructor, for a total of 14 periods. The seventh session is used to test the student for their temporary license (DTS-B form). These sessions are not designed to teach a student how to drive they are intended to refine their driving skills to insure they are ready to pass the DMV road test requirements. Additional behind-the-wheel private lessons are available to teach students how to drive. In the event that one-on-one driver training is permitted, the student is required to meet the observation requirements with at least one other student in the vehicle during in-vehicle training. Please contact the office to discuss student need for one-on-one driving. For all students, it is the responsibility of the student (if 18 or older) or the student’s parent or legal guardian (if under 18) to arrange for the student’s timely transportation to and from the agreed upon drop off/pick up location for behind the wheel instruction. Neither Drive This Way nor its instructors, agents, or employees assume responsibility for the supervision, health, safety or welfare of the student outside of the agreed upon period for behind the wheel instruction, and the instructor is not obligated to remain on site after the agreed upon period of behind the wheel instruction is completed. Please sign below to indicate that you have read this provision and agree to same. Students that are 18 years old and older who have held their learner’s permits for at least 60 days are not required to complete the behind the wheel sessions. They must have a completed CSMA-19 form and take the road test at the DMV. Students that are 18 and would like to complete the behind the wheel sessions and take the road test with us would receive a completed DTSD form to the DMV to receive their license. The client fully understands and agrees that no client is to be in a driver-training car with the motor vehicle running or with the keys in the ignition switch unless accompanied by a certified Drive This Way instructor. This contract constitutes the entire agreement between the student/parent/legal guardian and no verbal representation, assurance, or promises not contained herein shall bind the school or the student/parent/legal guardian. The instruction periods provided by Drive This Way does not guarantee that any student will pass the state license examination or that the student can secure a license, or that the student will be guaranteed employment upon completion of any course instruction. A minimum of 24 hours’ notice is required to cancel a behind-the-wheel lesson. Failure to provide such notice will result in a rescheduling fee of $25.00. Cancellations may be sent by e-mail or by direct contact with our office representatives. To retest for a license, there will be a $40.00 fee. Lost or misplaced DTS-B forms will be re-issued for a $25.00 administrative/processing fee. If the client terminates the contract, the $50 deposit will be forfeited, plus the cost of lessons already taken, provided that the school is capable and willing to perform its part of the contract within a reasonable time. If the school is unwilling or incapable of performing its part of the contract within a reasonable time, all pre-paid fees or costs will be refunded. Any NSF check or stop payment returned by a financial institution will be charged a fee of $50.00. The issuer of the check will be held responsible for all legal fees and costs associated with collection of NSF or stop- payment items. Our commitment is to provide our customers with the training and education they request. It our practice to provide you with accurate information regarding DMV procedures and regulations. Drive This Way is not responsible for any miscommunication between you, DMV or any other person or agencies. The client fully understands and agrees that successful completion of the Drive This Way behind-the- wheel course does not imply that the client is an accomplished driver. No one can be considered a skilled driver until he/she has driven for several years in various types of traffic and road conditions. The Department of Motor Vehicles is committed to promoting transportation safety through the certification of quality driver training programs. If you have any comments or concerns about this course, call the DMV toll- free at 1-877-885-5790. Rev 5/9/19I have read and fully understand all parts of this agreement.*By signing below, you agree to the terms and conditions above. You also agree that all credit card payments are processed using PayPal. If you choose to pay using another method you agree to send your deposit or full payment within the same week you send this form. If you choose to pay a deposit, your final payment must be complete before or on your training class date in order to begin. If you fail to pay on time you may loose your scheduled spot.Do you authorize one-on-one driving if needed due to a last minute cancellation?*Students under the age of 17 are required to have 7/7 50-minute sessions of driving. This consists of seven periods of driving and seven periods of observation with a certified, DMV- approved instructor, for a total of 14 periods. The seventh session is used to test the student for their temporary license (DTS-B form). In the event that one-on-one driver training is permitted, the student is required to meet the observation requirements with at least one other student in the vehicle during in-vehicle training. Please contact the office to discuss student need for one-on-one driving. Parent/Guardian consent is required if one-on-one driving is needed due to a last minute cancellation.YesNoI am a student over the age of 17Signee Name* First Name Last Name Relationship to Student*Type "Myself" or "NA" if you are signing for yourself.IMPORTANT!You will be re-directed to PayPal when you click the button below. You must complete your PayPal transaction in order for your credit card payment to go through. If you do not see an email from PayPal with your receipt, please give us a call to let us know. Our payment gateway is PCI compliant to securely accept online payment using PayPal. OptionFirst OptionSecond OptionThird OptionPhoneThis field is for validation purposes and should be left unchanged.