Additional Classroom Payment

Complete this form ONLY if you are currently in class or took class previously and are making an ADDITIONAL CLASSROOM PAYMENT.

Classroom Location*
- Mahtomedi HS
- Moundsview HS
- Irondale HS
- ONLINE
Class Start Date and Time*
Student's Full Legal Name*
First Middle Last
Date of Birth*
Phone Number*
Parent's Names*
Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
High School Student Attends*
Payment*
- (If $50 down payment) Remainder $245.00
- (If $100 down payment) Remainder $195.00
Gas Surcharge*
- Gas Fee, Pre-Paid Rate ($29.99)
- Gas Fee, Will pay at time of BTW (based on future fuel prices)
- Already Paid Gas Fee
Total
$0.00
Credit Card*

Discover
MasterCard
Visa
Supported Credit Cards: Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Parent Signature - I agree to requirements listed below:*
First Last
1. This contract expires two years from the start date of classroom. Any refund must be requested before that date.

2. If you choose to break up the classroom and BTW payment, the BTW portion will be billed at the rate current for that time.

3. If you choose to delay the Gas Surcharge Fee, you agree to pay the current rate at time of billing.

4. The first BTW lesson must be completed within four months of the student receiving their permit.

5. You can only schedule 1 BTW lesson at a time and the student should practice for at least 1 month between lessons.
REFUND POLICY: Registrations that are cancelled less than 7 days prior to the class start date are subject to a cancellation fee of $25. Cancellations more than 7 days from the class start date, will be refunded in full less a $10 fee for credit card refund processing fee.