1-12-2024 Virtual:

Segment 1 Virtual A Reusable form for each class

Set up a webhook into the following URL https://hooks.zapier.com/hooks/catch/9655963/26coi5c/ under settings->Integrations and it will feed the contacts into Clicksend and send out all the notifications automatically.
Program ID*
Date of Class

MonthDayYear
Best Location For Driver Pick-Up*
Full Birth Certificate Name Must Be Entered Exactly As It Is On Birth Certificate
Students First Name *
Students Full Middle Name (NO INTIALS)
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
Parent Email*

Confirmation Emailexample@example.com
Parent's Phone*
Please enter a valid phone number.
Student's Number*
Please enter a valid phone number.
Student Email*

Confirmation Emailexample@example.com
TEENAGE SEGMENT I (ONE) PROVISIONS
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?

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
Drivers License
date ofbirth
Does the student require any special accommodations to participate in the classroom phase
Please Explain
Class Time
Upload a copy of your students Birth Certificate. If you currently don't have one available, make sure your student has a copy to show on camera the first night of class.

Cancelof
My Products
prevnext( X )
OnLIne Segment 1 Drivers Education
$479

Processing Fee
$15

Total

$0.00
epoch difference
remainder for y/n)
Months
Month
Instructor Name
Instructor Phone Number
PRICE
479
Instructions (Parent)
Instructions (Student)
Program ID
Virtual location
Years
By Submitting This Form

Both Parent and Student agree to receive email and text communications regarding class and drive schedules as well as your students driving performance

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Segment 1 Virtual A Reusable form for each class

Full Birth Certificate 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 I (ONE) PROVISIONS

Registration Form

Drive Schedule Availability

By Submitting This Form