Clone of 1-02/23-26VIRTUAL Class Registration

Class Code

Class Dates

Student's First Name*

Student's Middle Name*

Student's Last Name*

Birth Date*

MonthDay4 Digit Year

Please upload a picture of students Birth Certificate*

Browse Files

Since we won't be seeing you in person the first day of class, you MUST upload a picture/copy of your birth certificate.

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

School Attended*

Parent/Guardian Name*

First NameLast Name

Phone Number*

Parent E-mail*

This e-mail will receive a confirmation receipt & the ZOOM link for class! Please look in your spam/junk folders

Student or Secondary E-mail*

This e-mail should also receive a confirmation/ZOOM link...we really want you to keep track of it...it's packed with IMPORTANT INFO!

Gender

FemaleMale

Is there another student in class that you would like to try and coordinate driving times with? (if yes, please list the name)

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

YesNo

Does the student require any special accommodations to participate in the behind-the-wheel phase (i.e. adaptive devices, an interpreter, etc.)?

YesNo

Is the student taking any medications that may affect his/her ability to drive a motor vehicle safely?

YesNo

Are there any medical conditions that would pose a concern with the student’s behind-the-wheel instruction (epilepsy, asthma, color blindness, hearing loss)?

YesNo

If you answered "yes" to any of the above questions, please explain here

Is the student’s visual acuity at least 20/40 corrected?

YesNo

In the last six months, has the student had a fainting spell, blackout, seizure, or other uncontrolled loss of consciousness?

YesNo

In the last six months, has the student had a physical or mental condition which might affect his/her ability to drive a motor vehicle?

YesNo

If the answer to the last 2 questions is yes, then the parent/guardian 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 PA 300

Comments or Extra Information

Barter proposals can go here too!

Link to get Zoom Link & Study Guide & Quizlet & Make-up Class

This address will take you to the page with all the Zoom links, Parent Meeting Video, the SEG 1 Study Guide & the Quizlet

Future Info From Mr.R's

Yes, I want to receive updates via e-mail! & I'm OK to communicate via text-message.

Parent Signature*

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

Student Signature*

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

Payment*

Pay with cardPay by phone/stop by with cash or check

My Products

SEGMENT ONE CLASS$520.00

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 ONE CLASS REGISTRATION