Online Registration

Fast and easy online registration.

Note: Online registration does not guarantee placement. You will be contacted regarding scheduling and placement.

Segment 1 Note: You are required to bring a certified birth certificate to the first class.

Student Information

First Name *

Middle

Last Name *

Birthdate * (must be 14y 8mo old)

Address

Street Address *

City *

State *

Zip *

Contact

Phone *

Email *

Parent / Guardian

Parent/Guardian Name *

Email Address *

Work Phone *

Cell Phone *

Emergency Contact

Emergency Contact *

Phone Number *

Preferred Class Date *

Additional Notes

Questionnaire

Does the student require any special accommodations to participate in the classroom phase (i.e., test 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? *

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

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 affected his/her ability to drive a motor vehicle safely? *

If the visual acuity answer is No, or either of the last two questions is Yes, the parent/guardian must provide a letter signed by the student's physician indicating the condition has been corrected and/or is under control, and the student meets the physical and mental requirements under Section 309 of the Michigan Vehicle Code, 1949 PA 300, MCL 257.309.

CertificationI certify that the information on this form is true and accurate to the best of my knowledge. *

Digital Signature *

Date *