Class Registration – Traffic Safety Association of Macomb County

1Student

2Segment 1 Info

3Segment 2 Info

4Certification

5Payment

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Class(Required)

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Location(Required)

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Start Date

MM slash DD slash YYYY

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End Date

MM slash DD slash YYYY

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Session Start Time

Hours

Minutes

AM/PM

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Session End Time

Hours

Minutes

AM/PM

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Payment Method

Full Online Payment

Pay in Person

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Class Schedule and Instructions

Student Name(Required)

First Middle Last

Enter Name exactly as it appears on your birth certificate.

Student Email(Required)

Student Phone(Required)

Student Date of Birth(Required)

MM slash DD slash YYYY

Must be verified by birth certificate: Student must be at least 14 years and 8 months of age by the first day of class.

Student Address(Required)

Street Address City State ZIP Code

Court Location or Probation Officer's Name(Required)

Case Number

How did you hear about us?

Parent / Legal Guardian's Name(Required)

Parent / Legal Guardian's Phone(Required)

Parent / Legal Guardian Address(Required)

Street Address City State ZIP Code

Emergency Contact(Required)

Emergency Contact Phone(Required)

Accommodations / Medical Condition

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

Yes

If yes, please explain:(Required)

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

Yes

If yes, please explain:(Required)

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

Yes

If yes, please explain:(Required)

4. Is the student's visual acuity at least 20/40 corrected?(Required)

Yes

If yes, please explain:(Required)

5. Are there any medical conditions/physical impairments that would pose a concern with the student's heind-the-wheel instruction (i.e., epilepsy, asthma, color blindness, hearing loss, physical impairment)?(Required)

Yes

If yes, please explain:(Required)

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

Yes

If yes, please explain:(Required)

7. 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?(Required)

Yes

If yes, please explain:(Required)

Upload a copy of birth certificate(Required)

Drop files here or

Max. file size: 8 MB, Max. files: 1.

If the answer to any of questions 5-7 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, MCL 257.309.

Date(Required)

MM slash DD slash YYYY

Parent/Guardian Waiver Agreement for Individualized On-The-Road Instruction

The law requires that TSA provide behind-the-wheel instruction with not less than 2 students in the training vehicle. That requirement may be waived if the parent/legal guardian signs the waiver agreement below, allowing for their son or daughter to be given individual lessons. The student must still complete at least four hours of observation time as a passenger in a driver education training vehicle being driven by another driver education student.

I allow my student to drive one-on-one with an instructor.(Required)

Yes

By selecting “No” I realize my student’s drives may be canceled or delayed to a later date.

By signing in the box below, I authorize the Traffic Safety Association of Macomb to allow a certified instructor, employed by the Traffic Safety Association of Macomb to offer my child on-the-road driving instruction without another passenger in the vehicle.

Student's driver's license number from permit

Upload a copy of student's driver's permit(Required)

Drop files here or

Max. file size: 8 MB, Max. files: 1.

Certification(Required)

I certify that all information contained within this document is true and accurate to the best of my knowledge.

Notice: This provider is required to be certified by the Secretary of State. If you have any complaint that cannot be settled with the provider, please complete the Driver Education Complaint form found on the Department of State website: www.michigan.gov/teendriver. Completion of driver education does not guarantee qualification for a driver license.

Parent / Legal Guardian Signature(Required)

Date(Required)

MM slash DD slash YYYY

Student Signature(Required)

Date(Required)

MM slash DD slash YYYY

THINK Program (THINK)

Price:

Coupon Code

Enter a coupon code if you have one.

Credit Card(Required)

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