Driversity™ of Antioch - Driver Training Enrollment Form

Please note: This form is for the Antioch Location ONLY.

For Concord go here. For Dublin location go here. For the Alameda and San Leandro locations go here.

*Is a required field

Student Section
* Student's first and last Name		* Address
*City , CA	*Zip	* Phone:	*Cell Phone:
* Student e-mail:		* Student's High School :	* DOB:
Parent Section
* Parent or Guardian First and Last Name:		* Phone:	* Cell Phone:
* Parent e-mail :		Additional Info

Enter your status as a former, current, or future Driversity or I-Virtual High student. Enter former, current or new in the box to the right.

*Student Status:

Indicate how you would like to pay the administrative fee. You can use our secure shopping cart here (will open a new window). You can call the office and pay over the phone, or we can contact you as well.

*Method Of Payment:

Please acknowledge that you have read and the following terms and conditions by entering your initials in the box below.

1.	It is agreed that you are enrolling in Driversity's driver training course.
2.	It is agreed that a non refundable administrative enrollment fee for enrollment is assessed. The fee for a new student is $30. A $15 fee is charged for a returning Driversity, LLC, or I-Virtual High student.
3.	It is agreed that you may have the certificate sent to you or you may pick the certificate up from the Antioch office between 12pm and 4pm M-F.
4.	You are acknowledge that you are within the range of the Concord location. *If you are not see the note above at the top of this form.*
5.	You understand that once the certificate is issued the fee is not refundable for any reason.
6.	You have read the 1-5 above.
Enter Initials here:

*Who is completing this form? (Parent, Student, etc.)

By signing below you agree to abide by the rules set forth in the course. Please sign by typing in your name.

* Parent Signature

* Student Signature