SEGMENT 1 REGISTRATION FORM

STUDENT FULL NAME:                                        

ADDRESS:  CITY:

ZIP CODE:      HOME PHONE:

BIRTH DATE:         VERIFIED BY BIRTH CERTIFICATE

CLASS LOCATION:

DATES OF CLASS:

Student must be at least 14 years and 8 months by the first day of class

PARENT/GUARDIAN’S NAME: WORK PHONE:

EMERGENCY CONTACT: PHONE:

1. Does the student require any special accommodations to participate in the classroom phase (i.e., test being read to him/her, an interpreter, seating arrangements, etc.)? Yes  No

If Yes, please explain:

2. Does the student require any 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. Are there any medical conditions that would pose a concern with the student’s behind-the-wheel instruction (epilepsy, asthma, color blindness, hearing loss)? 

Yes   No   If Yes, please explain: 

5.      Is the student’s visual acuity at least 20/40 corrected?  Yes   No

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 question 5 is no, or either of questions 6 or 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.

CERTIFICATION:  I certify that the information on this form is true and accurate to the best of my knowledge.

BY ENTERING YOUR NAME IN THIS SECTION, YOU ARE ELECTRONICALLY SIGNING YOUR NAME.

PARENT SIGNATURE                                             STUDENT SIGNATURE

DATE