Segment 2 Contract/Registration Form - Traffic Safety Association of Macomb County / Alcohol Highway Safety Program

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 Country
Home Phone
Cell Phone
Student'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 Phone
Parent/Guardian Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
TEEN SEGMENT 2 PROVISIONS
1. 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.
2. Classroom instruction shall not exceed 2 hours per day.
3. 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
1. 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
2. In case of an illness or emergency, make up classes will be offered during the next Segment 2 class.
REQUIREMENTS TO PASSING THE COURSE
1. Students must complete all homework and receive an overall grade of 70% on daily quizzes/test
2. Students must pass the State Exam with 70% or higher. Student will be given up to 1 additional attempt to pass the test.
3. 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:
1. Before the first scheduled Segment 2 class: Full refund shall be issued
2. 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