Select Driving Academy LLC | SEGMENT 2 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 #: S2/ / /
TEEN SEGMENT 2 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 2 PROVISIONS
1. Select Driving Academy LLC will provide a minimum of 6 hours of classroom instruction with a certified Michigan Driver Education Instructor. Classroom instruction shall not exceed 2 hours per day.
2. A driving log must be presented to verify that the student has completed a minimum of 30 hours of driving (including 2 hours of nighttime driving) were completed with a licensed parent, legal guardian, or licensed driver 21 years of age or older designated by the parent or legal guardian before beginning the course. A log must be presented to the Segment 2 instructor on or before the first classroom session.

Parent or Student Initials initials* -------- Seg. 2 Instructor Initals L.J

3. The student must have held a Level 1 License for not less than 3 continuous months.

Parent or Student Initials initials* --------- Seg. 2 Instructor Initals L.J

4. GDL/Permit #: * --------- Issue Date: *
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.

TEEN SEGMENT 2 TERMS
1. The Parent or Legal Guardian agrees to pay the total amount of $95 one week prior to the first day of class to ensure enrollment, in the form of cash, check, Venmo, Zelle or credit card ($7 fee applies)
2. 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 2 and must attend day 2 of the next available segment 2 course).

REQUIREMENTS TO PASS THE COURSE
1. The student must complete 6 hours of classroom instruction.
2. The student will be allowed up to three attempts to pass the State Exam, which requires a score of at least 70.

REFUND POLICY
1. After the beginning of the first-class session, NO REFUND shall be given.
ACCOMMODATIONS/MEDICAL CONDITIONS
1. Does the Student require any special accommodation to participate in the classroom phase (e.g., test being read, interpreter, etc.)?
Yes No*
Please explain:*
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 $95 on or before the first day of class. Partial payment shall not be accepted.
Payment Method (check one):*

CashCheckCredit Card ($10 fee applies)Venmo @Luay-JazrawiZelle @selectdrivingacademy@gmail.com
If the payment has already been made, please fill in the details below.
Amount Paid ($)
Payment Date

MonthDayYear
Should be Empty: