Clone of 1-09/14-26VIRTUAL Class Registration

VIRTUAL-SEGMENT ONE CLASS REGISTRATION

LIVE ONLINE: September 22-October 16; Tuesday-Thursday: 10am-12pm (Last class meets Friday, October 16; 10am-12pm IN-PERSON at Haslett Office)
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. Cancelof
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Attended
Parent/Guardian Name

First NameLast Name
Phone Number
This would be our primary way of contacting your family via phone
Parent #2 Phone Number
This would be our #2 way of contacting your family in regards to your student
Student Phone Number
This would be our #3 way of contacting your family in regards to your student
Parent E-mail

Confirmation EmailThis e-mail will receive a confirmation receipt & the ZOOM link for class! Please look in your spam/junk folders
Secondary (parent #2) E-mail
This e-mail should also receive a confirmation; we really want you to keep track of it...it's packed with IMPORTANT INFO!
Student/Other (parent #3?) E-mail

Confirmation EmailThis 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
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.)
Does the student require any special accommodations to participate in the behind-the-wheel phase (i.e. adaptive devices, an interpreter, etc.)?
Is the student taking any medications that may affect his/her ability to drive a motor vehicle safely?
Are there any medical conditions that would pose a concern with the student’s behind-the-wheel instruction (epilepsy, asthma, color blindness, hearing loss)?
If you answered "yes" to any of the above questions, please explain here
Is the student’s visual acuity at least 20/40 corrected?
In the last six months, has the student had a fainting spell, blackout, seizure, or other uncontrolled loss of consciousness?
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?
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
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

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SEGMENT ONE CLASS$550.00

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Subtotal Tax Total $0.00

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

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VIRTUAL-SEGMENT ONE CLASS REGISTRATION

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