Select Driving Academy LLC | SEGMENT 1 CONTRACT

Select Driving Academy LLC

3041 Chickering Lane, Bloomfield Hills, MI 48302 | Phone# (248) 895-4767 | Email: Selectdrivingacademy@gmail.com | Office Hours: Monday – Friday, 7:00 p.m. – 9:00 p.m. | Classroom Location: Marian High School Bloomfield, Michigan
Office use only: State Certification # P000745 -
Program Number #: S1/ / /
TEEN SEGMENT 1 CONTRACT
Certified PDF
Form Date*

MonthDayYear
Date
Student Information
Student First and Last Name*

First NameLast Name
Do you have a middle name?*

YesNo
Middle Name*
Student Phone Number*
Please enter a valid phone number.
Student Email*
example@example.com
Student Date of Birth*

MonthDayYear
Student Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Legal Guardian’s Information
Parent/Legal Guardian’s Name*

First NameLast Name
Parent’s/Legal Guardian’s Phone Number:*
Please enter a valid phone number.
Parent/Legal Guardian Email:*
example@example.com
Parent/Legal Guardian’s Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Class Date | Registration Deadline is one day before the start of each class*
TEEN SEGMENT 1 PROVISIONS
1. Select Driving Academy LLC 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. Select Driving Academy LLC will conduct the BTW instruction in a dual-controlled automobile that is insured by the Provider to cover each student enrolled in the program.
4. 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 with the registration form.

TEEN SEGMENT 1 TERMS
1. The Parent or Legal Guardian agrees to pay the total amount of $475 one week prior to the first day of class to ensure enrollment, in the form of; cash, check, Venmo, Zelle, or Credit Card ($15 fee applies)
2. Behind-the-Wheel Instruction: There will be a $30.00 fine for each 1-hour driving session that the student is late to or that they miss. A fee of $30.00 will be charged if 24 hours advance notice is not given for a driving appointment cancellation. A fee of $25.00 will be charged for any Observation hours scheduled and missed. A fee of $40.00 will be charged for a NO SHOW without notice.
3. The student may miss class only for an illness or emergency with documented proof presented to the instructor. The student is required to make up the same class session missed (e.g., The student missed day 5 then must attend day 5 of the next available segment 1 course.)

REQUIREMENTS TO PASS THE COURSE
1. The student will be allowed up to three attempts to pass the State Exam, which requires a score of at least 70%.
2. The student must complete 24 hours of classroom instruction, 6 hours of Behind-the-Wheel (BTW) instruction, and 4 hours of observation.

REFUND POLICY
Before the beginning of the third-class session, 50% of the total tuition will be refunded if no BTW instruction was given. After the beginning of the third-class session, no refund shall be given.

Behind the Wheel Waiver
I understand that my son/daughter must still complete at least 4 hours of observation time as a passenger in a driver education vehicle being driven by another driver education student.
Section 33 (d) of the Driver Education Provider and Instructor Act requires that at least two students must be in a vehicle during BTW instruction unless a parent waives this requirement in writing.*

I, the Parent/Legal Guardian of the Student, waive this requirement.I decline this waiver
Student Signature: * Date: *
Parent/Legal Guardian’s Signature*

Clear
Date*

MonthDayYear
Select Driving Academy LLC.
Provider Signature: Date: {date133}
NOTICE - This provider is required to be certified by the Secretary of State. If you have any complaint that cannot be settled with the provider, please complete the DES-P11 Statement of Complaint form found on the Department of State website; Michigan.gov/DriverEd. Completion of driver education instruction does not guarantee qualification for a driver license.

PAYMENT RECEIPT

The Parent or Legal Guardian must pay the total amount of $475 on or before the first day of class. Partial payment shall not be accepted.
Payment Method (check one):*

CashCheckCredit Card ($15 fee applies)Venmo @Luay-JazrawiZelle @selectdrivingacademy@gmail.com
If the payment has already been made, please fill in the details below.
Amount Paid ($)
Payment Date

MonthDayYear
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