2-12/09-24VIRTUAL Class Registration

Class Code

This is the official class code that the State requires to be on your documents

Class Dates

First Name*

Middle Name*

Last Name*

Birth Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

When did you get your Level 1 License?*

MonthDayYear

Driver's License #

This is near the top of your Level 1 License

Please take a picture of the front side of your Level 1 License*

Browse Files

You must have your Level 1 License for at least 3 months to be eligible for class AND the date MUST BE LEGIBLE!

Please take a picture/screen shot of your driving log.*

Browse Files

You must have at least 30 hours to be eligible for class

Where did you take Segment 1 class?*

High School Attended*

Parent/Guardian Name*

First NameLast Name

Phone Number*

Parent/Guardian E-mail*

This e-mail will receive a confirmation receipt. That email will also have the Zoom link you need to get into class -so KEEP TRACK OF IT!

Student or Secondary E-mail*

This e-mail will ALSO receive a confirmation so you have more chances NOT to lose it!

Gender

FemaleMale

Does the student require any special accommodations toparticipate in the classroom phase (i.e., test being read to him/her, an interpreter, seating arrangements, etc.)?*

YesNo

If 'Yes', please explain:

Comments or Extra Information

Link to Zoom Links and Study Guide

Follow this address to the Zoom links for class and the SEG 2 Study Guide

Future Info From Mr.R's

Yes, I want to receive updates via e-mail!

Parent Signature

This is signing that you have read and agree to the terms & conditions

Payment*

Pay now with cardPay by phone/drop off cash/check

CHECKOUT*

SEGMENT TWO CLASS$100.00

Enter coupon

Subtotal $0.00Tax $0.00Total $0.00

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

VIRTUAL-SEGMENT TWO CLASS REGISTRATION