Contract # _______________

Date: __________________

Student’s legal name:
Last

First

Date of Birth: ____________________

Middle

Phone #: ________________

Address: ______________________________________________________________________________________
City: _____________________________

State: _____________________

Email: _________________________________________

Zip code: ______________

School: ___________________________________

Parent / Guardian’s name: _________________________________________Phone: _____________________
Road Skills, Inc. agrees to provide the applicant the following driver’s education program:
 Premium Package: 30 hours of classroom instruction + 6 hours of behind the wheel instruction / practice as mandated by the State of Indiana + your choice of 2 hours of remedial practice or 2 hours of advanced practice
Downtown Indianapolis ................................................................................................................ $499.95
 Regular Package: 30 hours of classroom instruction + 6 hours of behind the wheel instruction / practice as mandated by the State of Indiana ................................................................................................ $429.95
 Behind-the-wheel Package: 6 hours of behind the wheel instruction / practice as mandated by the State of
Indiana for students who are taking the class component online .................................................. $330.00
The program will run from _____ / _____ / _______ to _____ / _____ / ________
On

Monday

Tuesday

Wednesday Thursday

Friday

Saturday

Sunday

From _________ a.m. p.m. to _________ a.m. p.m.
Add-ons:
 Extra driving hours can be scheduled at the cost of $55.00 / hour
 The road test can be added to any package for $35.00.

Qty: _____

Payment:
