ADULT APPLICATION AND AGREEMENT 
(make checks payable to) MAD-AREA DRIVING SCHOOL Contract No. ______________      
Send to    

913 Lorena Pkwy      Madison, WI 53713-3373 e-mail      jkapinus@madareadriving.com

Appointments/Questions  (608) 345-9598 8am-10:00am or 4pm-5:30pm Mon.-Fri

Student Name: __________________ Birth Date:  __/__/___  Student  #______________   
Address:______________________________________ Email: ____________________
I  hereby make application to MAD-AREA DRIVING SCHOOL.     
 beginning on ___/____/____    
-ADULT  BEHIND THE WHEEL-
[] $70.00 I agree to pay a fee of $70.00 per hour for each hour of behind-the-wheel instruction.
-SPECIALS-

=4x6 (Save $30.00)=  [] $390.00 A TOTAL OF FOUR  one and A HALF hour sessions (equivalent of  6-1 hour sessions)

=6x9 (Save $50.00)=  [] $580.00 A TOTAL OF SIX  one and A HALF hour sessions!!(equivalent of  9-1 hour sessions BEST VALUE)

=1.5= (Save $10.00) [] $95.00  per each One and A HALF hour session

-SPECIAL ROAD TEST FEE FOR  MAD AREA STUDENTS ONLY*-
[] $70.00 I certify that I am a student of mad-area driving and I agree to pay a fee of $70.00 for use of driver education vehicle when taking the road test.
*To qualify you must have taken lessons with Mad-Area Driving School prior to taking the road test.-
-FAILURE TO YIELD RIGHT-OF-WAY/ADULT  REFRESHER COURSE-   [] ONLINE    [] CLASSROOM
  $ 95.00 I agree to pay a total fee of $95.00 for a two hour traffic safety referesher course of classroom instruction designed to reacquaint an operator with vehicle
   right-of-way rules and provide awareness of keeping motorcyclists, pedestrians and bicyclists safe.
-DANE COUNTY PICKUP/DROPOFF FEE-
Free Pickup for all students within 2 miles of Mad-Area (913 Lorena Pkwy)=
[] $5.00  =PICKUP & DROPOFF FOR ALL STUDENTS WITHIN 3-7 MILES OF MAD-AREA (913 Lorena Pkwy)=
[] $10.00  =PICKUP & DROPOFF FOR ALL STUDENTS WITHIN 8-12 MILES OF MAD-AREA (913 Lorena Pkwy)=
[] $15.00  =PICKUP & DROPOFF FOR ALL STUDENTS WITHIN 13-17 MILES OF MAD-AREA (913 Lorena Pkwy)=
ATTENTION: BECAUSE OF THE UNSTABLE GAS PRICES WE WILL BE CHARGING AN EXTRA $2.00 FOR EACH DOLLAR INCREASE AT OR ABOVE $4.50 PER GALLON AT THE KWIK TRIP. THIS FEE WILL NEED TO BE PAID AT EACH BEHIND THE WHEEL LESSON.
Due to additional cost and inconvenience,  -I also agree to pay $30.00 for each 1 hour missed b-t-w appointment or cancellation not called in 48 hours in advance.
In order to better serve all customers, we reserve the right to delay or reschedule service.
This agreement constitutes the entire contract between the driving school and the student, and no verbal statement of promises will be recognized. 
The school will not refund any tuition or part of tuition if the school is ready, willing, and able to fulfill its part of this agreement .

_______________________________      ___________________________________   
 Signature of Student                                                          Signature of Driving School Representative  
Note you may copy and paste this into an e-mail be sure to type your name in the signature box -this will constitute an electronic signature.