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Online Request for Enrollment
  
Please note: This form is for the Dublin Location ONLY.
For the Antioch or Concord locations go here. For the Alameda and San Leandro locations go here.
*Is a required field
Student Section
* Student's first and last Name
* Address
 * DOB: mm/dd/yy
*City
, CA *Zip 		* Phone:
*Cell Phone:
* Student * High School Student Attends :  
Parent Section
* Parent or Guardian First and Last Name:
* Phone:
* Cell Phone:
* Parent e-mail :
 Additional Info

Enter former, current or new -------------------> *Student Status:
Enter the course you are enrolling or are enrolled in. Use the select field below. Select and enter in this box ----------> *Course:
If your enrollment is in driver training (you have your permit), please enter your permit number in the box provided. If you don't have a permit enter none. -------> *Permit Number:
Select and enter in this box ---------------> *Method of Payment :
*Who is completing this form?  (Parent, Student, etc.)  
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 into a Driversity of Dublin course.

2.

It is agreed that a non refundable administrative enrollment fees for enrollment may be charged for issuing a driver training enrollment form.
3. It is agreed that if a certificate is issued upon your request, the certificate will be sent to you. You may pick the certificate up from the Dublin office however, you must request this.
4. You understand that once the certificate is issued the fee is not refundable for any reason.
5. For the driver training course, you are acknowledge that you are within the range of the Dublin location. If you are not see the note above at the top of this form.
6. You have read the 1-5 above.
Enter Initials here:
* Student Signature
Driversity of Dublin, LLC & Tri Valley High
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