Segment 2 Contract/Registration Form Driver Education Segment 2 Contract/Registration Form ENTER NAME EXACTLY AS IT APPEARS ON YOUR BIRTH CERTIFICATE* First Middle Last Date of Birth* MM slash DD slash YYYY ** VERIFIED BY BIRTH CERTIFICATE ** Student must be at least 14 years and 8 months by the first day of class.Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneStudent's Driver License Number from Permit: Upload A Copy of Student's Driver's Permit*Max. file size: 32 MB.Parent/Legal Guardian's Name* Parent/Legal Guardian's Home/Cell PhoneParent/Guardian Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code TEEN SEGMENT 2 PROVISIONS The Traffic Safety Association of Macomb (TSA) will provide a minimum of 6 hours of classroom instruction provided by a certified Michigan Driver Education Instructor. Classroom instruction shall not exceed 2 hours per day. For a student to participate in Segment 2, a verification log must be received that the student has completed a minimum of 30 hours of driving (including 2 hours at night) with a licensed parent or guardian (or parent designee) on a level 1 license, which has been held for not less than 3 continuous months. TEEN SEGMENT 2 TERM The Parent or Legal Guardian agrees to pay the total class fee on or before the first day of class in the form of cash, check or Credit/Debit In case of an illness or emergency, make up classes will be offered during the next Segment 2 class. REQUIREMENTS TO PASSING THE COURSE Students must complete all homework and receive an overall grade of 70% on daily quizzes/test Students must pass the State Exam with 70% or higher. Student will be given up to 1 additional attempt to pass the test. Lost or damaged Textbook or Workbook will be charged a fee of $50.00 each. REFUND POLICY If for any reason you decide to withdraw from the course, your refund will be based on the following: Before the first scheduled Segment 2 class: Full refund shall be issued During the first scheduled Segment 2 class and thereafter: No refund shall be issued. CERTIFICATION:* I certify that all information contained within this document is true and accurate to the best of my knowledge. Signature
