2-05/26-26VIRTUAL Class Registration

VIRTUAL-SEGMENT TWO CLASS REGISTRATION

ONLINE: May 26, 27, 28 & 29; Tuesday, Wednesday, Thursday= 6-8pm: LIVE ONLINE; Friday, May 29=5-5:30pm IN-PERSON in Haslett
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

CityState / Province

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

Browse Files
You must have at least 30 hours to be eligible for class Cancelof
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
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.)?
If 'Yes', please explain:
Comments or Extra Information
Barter proposals would go here too!!
Link to Zoom Links & Study Guide & Quizlet & Make-up classes
Follow this address to the Zoom links for class, the SEG 2 Study Guide & the Quizlet
Future Info From Mr.R's
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

CHECKOUT

SEGMENT TWO CLASS$100.00

Enter coupon

Subtotal Tax Total $0.00

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

VIRTUAL-SEGMENT TWO CLASS REGISTRATION

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