CaroTC 2-7-2024:

CaroTC Segment 2 Master A Reusable form for each class

Set up a webhook into the following URL (https://hooks.zapier.com/hooks/catch/9655963/beid38h/) under settings->Integrations and it will feed the contacts into givesend go and send out all the notifications automatically.
Program ID
Date of Class

MonthDayYear
Classroom Location
Tuscola Tech Center, Rm 201, 1401 Cleaver Rd (M-24), Caro, 1/2 mile North of Walmart
Full Name Must Be Entered Exactly As It Is On Birth Certificate
Students First Name *
Students Full Middle Name
If Your Student DOES NOT have a Middle name on their Birth Certificate Click Here

X
Students Last Name *
Address
Date of Birth*

MMDDYYYY
Street Address*
City*
State*
Zip*
Below is the calculated age of your child on the first day of this class. If it is less that 14.08 Your Student is not eligible. Check Birth Date for typo or sign up for a later class.
Calculated Age
Communications*

By clicking here you give us permission to Email or Text you regarding your students classroom or driving schedule changes or activity.
Parent's Phone*
Please enter a valid phone number.
Student's Number*
Please enter a valid phone number.
Email*

Confirmation Emailexample@example.com
TEENAGE SEGMENT II (TWO) PROVISIONS
1. MR. R's A+ DRIVING SCHOOL will provide 6 hours of classroom instruction. Classroom instruction shall not exceed 2 hours per day. 2. Upon successful completion, (attendance 6hrs, classroom assignments, 70% on State test) the student will be issued a "MICHIGAN DRIVER EDUCATION CERTIFICATE OF COMPLETION - SEGMENT TWO" certifying completion of the requirements of the Mich.Department of State.

A $20.00 replacement fee will be assessed for issuing a new certificate.

The Parent or Guardian authorizes the Student to take part in the program on the basis that the Student meets the physical requirements specified by law for issuance of a motor vehicle operator's license. For a student to take part in Segment 2, verification must be received that the student has completed a minimum of 30 hours of driving (including 2 hours at night) with a licensed parent or guardian ( or parent designee) on a level 1 license, which has been held for not less than 3 continuous months.

The Parent or Guardian agrees to pay the amount of $60

In case of a student's absence or emergency the school policy is that the class must be made up at a later date.

If for any reason you decide to withdraw from the course before its completion, your refund will be based on the following pro-rated schedule: A. After the first day a refund of $20 will be refunded. B. After the first two days NO REFUND WILL BE issued.

WE, THE UNDERSIGNED, UNDERSTAND THE ABOVE PROVISIONS.
NOTICE STATEMENT: This provider is required to be certified by the Secretary of State. If you have any complaint, which you cannot settle with this provider, write: Michigan Department of State, Driver Programs Division, Lansing, Michigan 48918. Completion of driver education instruction does not guarantee qualification for a driver license.
Registration Form

Emergency Contact/Medical
Parent/Guardian Work Phone
Please enter a valid phone number.
Emergency Contact*
Emergency Number*
Please enter a valid phone number.

Accommodations / Medical

	Yes	No	If/Yes/Please/Explain
1. Does the student require any special accommodations to participate in the classroom phase (test being read to him/her, an interpreter, seating arrangements, etc.)?
2. Does the student require any special accommodations to participate in the behind-the-wheel phase (i.e. adaptive devices, an interpreter, etc.)?
3. Is the student taking any medications that may affect his/her ability to drive a motor vehicle safely?
4. Are there any medical conditions that would pose a concern with the student's behind-the-wheel instruction? (epilepsy, asthma, color blindness, hearing loss)?
5. Is the student's visual acuity worse then 20/40 corrected?
6. In the last six months, has the student had a fainting spell, blackout, seizure, or other uncontrolled loss of consciousness?
7. In the last six months, has the student had a physical or mental condition which affected his/her ability to drive a motor vehicle safely?

Save for future use
Double Check Your Answers

If the answer to questions 5, 6 or 7 is yes, then the parent/guardian of a Segment 1 student must provide a letter signed by the student's physician indicating that the condition has been corrected and/or is under control, and the student meets the physical and mental requirements for a motor vehicle operator's license under Section 309 of the Michigan Vehicle Code, 1949 P A 300, MCL 257.309.
By signing below I
Parent or Guardian
authorize MR.R’S A+ DRIVING SCHOOL, to allow a certified instructor employed by the provider, to Offer my child On-The-Road driving instruction without another passenger in the vehicle.
Parent or Guardian

Clear
CERTIFICATION: I certify that the information on this form is true and accurate to the best of my knowledge.

FURTHER WE, THE UNDERSIGNED, UNDERSTAND THE ABOVE PROVISIONS & TERMS
Parent/Guardian*

Clear
Student*

Clear
Sign Date*

MonthDayYear
Date
Drive Schedule Availability

Mr R's Will be scheduling 6 driving appointments with your student. We do are best to provide workable schedules. As you fill out this information, please think in terms of the 4 weeks following the start of class. The information you provide is used to schedule your student.
What school does your student attend
Is there a Student in this class that your Student MUST! share rides with,? IF so who? Please explain. (Keep in mind that if your Student is dependent on another student who has a busy schedule: practice, camps, travel leagues, that YOUR student may be delayed in completing the drives.)
If your student has Any Days or Half Days Off School in the 4 weeks after class starts , will they have transportation to get back and forth to Driving Appointments ? *
IMPORTANT

We will need to schedule 6 drives for your student. These drives are normally scheduled in two hour blocks(1 period observation/1 period driving). We need to know when your students WILL NOT be available for drives for the 4 weeks begining on their first day of Drivers Ed. Try to be as generous as possible, we will be scheduling 20 or more students. 20 students means 20+ busy families. Please think in terms of their Transportation, School, Sports, Extracurricular and Family Activities. Select the time periods when your student WILL NOT be available to drive.
(SCROLL) this table right and left On Cell Phones

My Student WILL NOT BE AVAIABLE on these weekdays at the following times for the 4 weeks after Drivers Ed starts

	Mon	Tue	Wed	Thr	Fri	Comments
10:30 -am- 12:30
12:30 -pm- 2:30
After school -pm- 4:30
4:30 -pm- 6:30
6:30 -pm- 8:30

My Student WILL NOT BE AVAILABLE on these weekend days at the following times for the 4 weeks after Drivers Ed Starts

	Saturday	Sunday	Special/Notes/Cncerns
10am-2pm
2pm-6pm

Instructor Sign
Student
STUDENT's Drivers License # (Please Dbl Chk)*
See Image Below
date ofbirth
Does the student require any special accommodations to participate in the classroom phase
Please Explain
Class Time

Segment 2*

Segment 2 Non-Refundable Booking FeeThe booking fee is non-refundable and holds your students place in this class. The Segment 2 class fee of $60 will be due on the first day of class.

$10.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

epoch difference
remainder for y/n)
Years
Months
Month
Instructor Name
Instructor Phone Number
PRICE
60
Instructions (Parent)
their license, driving log and payment for Segment 2
Instructions (Student)
Should be Empty:

CaroTC Segment 2 Master A Reusable form for each class

Full Name Must Be Entered Exactly As It Is On Birth Certificate

Below is the calculated age of your child on the first day of this class. If it is less that 14.08 Your Student is not eligible. Check Birth Date for typo or sign up for a later class.

TEENAGE SEGMENT II (TWO) PROVISIONS

Registration Form

Drive Schedule Availability