SafeSTART Driver’s Education Registration

SafeSTART Driver’s Education Registration
Student Name

First NameLast Name
Student’s Email
example@example.com
Student’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student’s Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student’s Attending School
Student’s Grade in School
Does student have a learner’s permit?
Parent/Guardian Name

First NameLast Name
Parent Email
example@example.com
Parent Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Course Registration
Select the Month you are registering for:
Which program are you registering for?
How did you hear about SafeSTART?
PARENT AGREEMENTS

Use Checkboxes (required).
Parent/Guardian Acknowledgement. Please review our policies before completing your registration.
ELECTRONIC SIGNATURE

Parent/Guardian Signature
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

YOUR ALMOST FINISHED!

Your registration information has been completed. The final step is to choose your payment method to reserve your student's spot.
RESERVE YOUR SPOT

STEP 1: Please select one Payment Option below. STEP 2: Click NEXT.
RESERVE YOUR SPOT Choose one of the following payment options:
Important Payment Information

Your student’s spot is not reserved until today’s required payment is received. Cash and check may be used for remaining payment-plan installments after the initial payment has been made.

Full Course

30 hours of classroom

6 hours of driving

$515.00 Quantity

Initial Payment – Reserve Your Spot

Required initial payment to reserve your student’s spot.

This payment is applied toward your total course cost.

Remaining balance may be paid by credit/debit card, Venmo, cash, or check.

$128.75 Quantity

Total

COMPLETE YOUR VENMO PAYMENT

Thank you for registering with SafeSTART Driver’s Education. To reserve your student’s spot, please complete your Venmo payment using the information below.
VENMO – PAY IN FULL
$500 DUE TODAY
Scan the QR code below to complete your $500 payment and reserve your student’s spot.
VENMO – FIRST PAYMENT
$125 DUE TODAY
Scan the QR code below to make your $125 initial payment and reserve your student’s spot.
VENMO INFORMATION

Venmo Username: @Heidi-Hill-43 or SCAN QR Code Below Please include the student’s first and last name and the class month in the payment note. Example: John Smith - August
Important

Your student’s spot is not reserved until your Venmo payment has been received and verified by SafeSTART Driver’s Education
Venmo Account Name used to submit payment.
Payment Confirmation
Questions?

📞601-941-1803. ✉️safestartms@gmail.com 🌐www.safestartms.com

REMAINING BALANCE PAYMENT OPTIONS

Thank you! Your initial payment reserves your student’s spot with SafeSTART Driver’s Education.
Remaining Balance

Your initial payment:

Reserves your student’s spot in SafeSTART Driver’s Education
Provides access to the SafeSTART online curriculum
Is applied toward the total course cost

You may choose one of the following options for your remaining course balance:

OPTION 1 — PAY REMAINING BALANCE IN FULL
Pay your entire remaining balance on or before your student’s first driving session.

OPTION 2 — 3 REMAINING PAYMENTS
Split your remaining balance into 3 payments, with one payment due before each scheduled driving session.

Payment Amounts

Cash, Check or Venmo: $125 per payment
Credit/Debit Card: $128.75 per payment
Payment Schedule

Initial Payment — Paid at Registration
Payment 2 — Due before Driving Session 1
Payment 3 — Due before Driving Session 2
Payment 4 — Due before Driving Session 3
Important: All payments must be received before the scheduled driving session.
How would you like to pay your remaining balance?
Contact Information

📞Phone: 601-942-5986 ✉️Email: safestartms@gmail.com
How would you like to pay your remaining balance?

READY TO SUBMIT

Please review your information before submitting. By submitting this registration, you acknowledge the SafeSTART payment schedule selected above. Your student’s spot and curriculum access are confirmed once the required initial payment has been received.
I understand and agree to the payment schedule selected above.
Should be Empty:

Course Registration