Mid 1-10-2025:

Program ID
Midland Segment 1 A Reusable form for each class

Set up a webhook into the following URL https://hooks.zapier.com/hooks/catch/9655963/2rces13/ under settings->Integrations and it will feed the contacts into givesend go and send out all the notifications automatically.
Date of Class

MonthDayYear
Classroom Location
Eastlawn Plaza Location 921 S Saginaw Rd (entrance in back next to DQ)

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
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 I (ONE) PROVISIONS
1. Mr. R’s Driving School will provide a minimum of 24 hours of classroom instruction, 6 hours of behind-the-wheel (BTW) instruction and 4 hours of observation time with a certified Michigan Driver Education Instructor.

2. Classroom instruction must be a minimum of 3 weeks in length and shall not exceed 2 hours per day. BTW instruction shall not begin until the student has received a minimum of 4 hours of classroom instruction and must be completed no later than 3 weeks after the classroom instruction has been completed.

3. The student must be at least 14-years and 8-months of age by the first day of a Segment 1 course. Verification by birth certificate is required.

4. Mr. R’s Driving School will conduct BTW instruction in a dual controlled automobile that is fully insured by the Provider to cover each student enrolled in the program.

TERMS

The Parent or Legal Guardian agrees to pay the total amount of {price161} by the first day of class in the form of cash, check, Visa or MasterCard unless other arrangements are made.

If a student is absent from class they must attend a “make-up” class to be arranged with the instructor In the event of a driving appointment cancellation, a cancellation fee of $20.00 may be charged if 24 hours advance notice is not given. The student must complete 6 hours of BTW driving and 4 hours of observation to be arranged by instructor and the student.

REQUIREMENTS TO PASS THE COURSE

Pass the State of Michigan Test (70%)

The Student will be allowed up to 3 attempts to pass the State Exam, which requires a score of at least 70% The Student must pass ALL BTW Performance Objectives, per the Driver Education Provider and Instructor Act (DEPIA), at the instructor’s professional discretion with a satisfactory or higher grade.

Upon successful completion, (pass the state test at 70%, attendance for 24 hours of class, proficiently driving after 6 hours of BTW,4 hours of observation) the student will be issued a "MICHIGAN DRIVER EDUCATION CERTIFICATE OF COMPLETION SEGMENT ONE" certifying completion of the requirements of the Michigan Department of State. A $20.00 replacement fee will be assessed for issuing a new certificate. Segment One Certificate Of Completion will be issued when tuition is paid in full and all class requirements are met.

REFUND POLICY

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. Before the first class, 100% of tuition is refunded

B. During the first two classes, if no Behind -the-Wheel lessons were taken, 90% of the total tuition is refunded.

C. During the third and forth classes, if no Behind-the-Wheel driving lessons were taken, 75% of total tuition is refunded.

D. During the first four classes, if one hour of Behind-the-Wheel driving has been completed, 50% of total tuition is refunded.

E. During the first four classes, if two or more hours of Behind-the-Wheel driving has been completed, or at any time after the fifth class, no refund will be given.

WE, THE UNDERSIGNED, UNDERSTAND THE ABOVE PROVISIONS & TERMS
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
Drivers License
date ofbirth
Does the student require any special accommodations to participate in the classroom phase
Please Explain
Class Time
You may upload a picture of a birth certificate here if you dont have one handy make sure one is available to show the First night of class

Cancelof
Welcome to Segment One
prevnext( X )
10$ Non-Refundable Segment One Booking FeeThis Non-Refundable Booking fee secures your students seat. The remaining 484 will be due the first class.
$10.00

Pre Pay Segment 1 Drivers Education 484 + 3.1% CC processing fee Total: 499 The Pre-Pay amount is fully refundable if for some reason your student cannot start this class. IF you would like to pay over time Please check the PayPal Box Below
$499.00

Total

$0.00
Instructor Name
Instructor Phone Number
PRICE
484
Instructions (Parent)
a copy of their birth certificate and the payment for Segment 1
Instructions (Student)
Purchase Amount
Amount Due
Program ID
Virtual Location
epoch difference
remainder for y/n)
Years
Months
Month

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Midland Segment 1 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