Teen Segment 1 Contract Form Driver Education Segment 1 Contract 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 PhoneParent/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 Emergency Contact* Emergency Contact Phone*Class Location*-- Choose Class Location --Traffic Safey AssociationRoseville High SchoolDate of Class* MM slash DD slash YYYY Time of Class* : Hours Minutes AM PM AM/PM TEEN SEGMENT 1 PROVISIONS The Traffic Safety Association of Macomb will provide a minimum of 24 hours of classroom instruction, 6 hours of behind-the- wheel (BTW) instruction and 4 hours of observation time provided by a certified Michigan Driver Education Instructor. Classroom instruction must be a minimum of 3 weeks in length. BTW instruction shall not begin until the student has received a minimum of 4 hours of classroom instruction. BTW instruction must be completed no later than 3 weeks after the classroom instruction has been completed. The Traffic Safety Association of Macomb will conduct the behind-the-wheel instruction in a dual-controlled automobile that is fully insured to cover each student enrolled in the program. The student must be at least 14-years and 8-months of age by the first day of a Segment 1 course. Verification by birth certificate is required. TEEN SEGMENT 1 TERM s 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 the event of a driving appointment cancellation, a cash fee of $50 will be charged if 24 hours advance notice is not given. A student may miss up to two days with a reasonable excuse (illness, family matter). The days must be made up at the end of the class or in a future Segment 1 class. Student will still be responsible for any missed work/quiz/test to turn in. 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. Students must pass with satisfactory or higher, ALL BTW Performance Objectives, per the Driver Education Provider and Instructor Act (DEPIA) at the instructor’s professional discretion. 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: A $100 refund fee is assessed for cancellations prior to the class start date. During the first two class sessions, if no Behid-The-Wheel (BTW) lessons were given, 50% of the total tuition is refunded. During the third class session and thereafter, regardles of the amount of BTW lessons, no refund shall be granted. CERTIFICATON:* I certify that all information contained within this document is true and accurate to the best of my knowledge. SignatureThe 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. Parent/Guardian Waiver Agreement for Individualized On-The-Road Instruction 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.Date MM slash DD slash YYYY ________________________________________ Signature of Provider _____________ Date I understand that my son/daughter must still complete at least four hours of observation time as a passenger in a driver education vehicle being driven by another driver education student.
