Segment 1 Form Driver Education Segment 1 Registration Form Choose Location*-- Choose Class Location --Traffic Safety AssociationRoseville Hight School Depart of State Certification #P000649ENTER NAME EXACTLY AS IT APPEARS ON YOUR BIRTH CERTIFICATE* First Middle Last 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 Phone*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.Parent/Legal Guardian's Name* Parent/Legal Guardian's PhoneEmergency Contact* Emergency Contact PhoneACCOMMODATIONS/MEDICAL CONDITION 1. Does the student require any special accommodations to participate in the classroom phase (i.e., test being read to him/er, interpreter, eating arrangements, etc.)?* Yes No If yes, please explain:* 2. Does the student require special accommodations to participate in the behind-the-wheel phase(i.e., adaptive devices, an interpreter, etc.)?* Yes No If yes, please explain:* 3. Is the student taking any medications that may affect his/her ability to drive a motor vehicle safely?* Yes No If yes, please describe:* 4. Is the student's visual acuity at least 20/40 corrected?* Yes No 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)?* Yes No If yes, please explain:* 6. In the last six months, has the student had a fainting spell, blackout, seizure, or other uncontrolled loss of consciousness?* Yes No 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?* Yes No 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.Upload a copy of birth certificate:Max. file size: 32 MB.CERTIFICATION* 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 SignatureDate MM slash DD slash YYYY Student SignatureDate MM slash DD slash YYYY FIELDS TO BE COMPLETED BY PROVIDER Provider Name: Traffic Safety Association of Macomb Signature of Provider: __________________________________________________ Title: ___________________________________________________________________
