FAMILY DRIVING SCHOOL LLC
955 W HURON ST
WATERFORD MI 48328, (248)-281-3133/(248)-681-7228
Fax # 248-681-7547            familydrivingschool.net   P000001  State Certification

Student: (last)				(first)					(middle)		        	   	

Address:        	                                                             	        City:                                                 Zip:			

Home Phone:	                 					  Age:	  	D.O.B.:		              		                                     

Parent/Legal Guardian’s Name: 	              		 Parent’s/Legal Guardian’s Phone #:                     		

Parent/Legal Guardian’s Address:                         			City:			Zip:			 

Emergency Contact:                                 			Phone #:	                                         		               

Dates of Class: _____________________________________________________________________________________________                            

TEEN SEGMENT 1 PROVISIONS  
Tuition is $490 Payment plans are available before class starts. Everything must be paid in full on the first day of class. Segment one consists of 24 hours of classroom instruction, 6 hours of behind-the-wheel (BTW) instruction, and 4 hours of observation time in a dual controlled automobile, fully insured, covering each student enrolled into the program. All payments made to Family Driving School will be credited and available for 6 months, after 6 months payments will no longer be able to be used. Classroom instruction must be minimum of 3/4 weeks in length. BTW instruction shall not begin until the student has received a minimum of 4 hours of classroom instruction. Checks are accepted. All returned checks will be a $40.00 fee. Cancellations for behind-the- wheel driving instructions must be done 24 hours prior to your appointment; or the student will be assessed a $35.00 no show or cancellation fee which must be paid by their next appointed drive. Failure to pay may result in a termination or transfer. All extra drives (BTW) that go beyond 6 drives will be charged an additional $75.00 per drive. FAMILY DRIVING SCHOOL LLC reserves the right to cancel or reschedule courses or classes at its sole discretion. Each student will be allowed two absences. If a student is absent more than two days he/she will be transferred into another available Segment one class, each student will have 6 months from the date of transfer to complete segment one. A $35 transfer fee will be enforced. After 6 months, the student will be required to pay full tuition for Segment One class, unless other arrangements have been made. Tuition for Segment two is $95.00                                                                                                                                                                                          
TEEN SEGMENT 1 TERMS                                                                                                                                                                                                           
•	The student must be at least 14 years/8 months of age by the first scheduled day of class (Verification by birth certificate required.) Students 18 and older must sign up for the Adult Program $490.
•	The parent or guardian agrees to pay the amount of $490 by cash, money orders, debit, credit card, or check.                                                                                              
•	Requirements to pass the course: complete all classroom assignments, quizzes, pass and complete (BTW) drives and pass State Exam and must pass the final evaluation drive. All missed drives is a $40 fee.
•	The Required score to pass the STATE TEST is 70 %( Students must attend unless other arrangements have been made.)
•	The cost of materials and supplies for the class is $75 to replace segment one workbooks.
•	In case of an absence or emergency the schools policy is: all make up days will be assigned to the student therefore no certificates will be issued until all make up days has been completed.
*Transfer students are students who have not had misconduct behavior, failure to follow rules and regulations and failure to pass the State Exam on the third attempt. Students may transfer to the next available segment one class in  6 months’ time frame if they become ill, if their personal schedule conflicts with the course schedule, or any other reasonable reason that will restrain them for completing the course successfully. All transfer students must be approved by a Family Driving School representative and all payments will be applied towards segment one.

REFUND POLICY  
•	No refunds will be given.
•	Transfers will be allowed, refer to provisions on the contract.
BTW WAIVER

Section 33 (d) of the Driver Education Provider and Instructor Act requires that at least two students must be in a vehicle during BTW instruction unless a parent waives this requirement in writing.	
I, the Parent/Legal Guardian of the Student, waive this requirement.		
I understand that my son/daughter must still complete at least 4 hours of observation time as a passenger in a driver education vehicle being driven by another driver education student.	
Date:  			Student Signature:

Date:			Parent/Legal Guardian Signature:

Date:  			Family Driving School. By:                          	    Owner/President      	_____________                                                                                                         		                   Provider                                                                                               Signature of Provider Owner                                  Title)	
ACCOMMODATIONS/MEDICAL CONDITIONS 
•	Does the Student require any special accommodations to participate in the classroom phase (e.g., test being read, interpreter, etc.)?    Yes      No      If Yes, please explain:  	   			 				
•	Does the Student require any special accommodations to participate in the BTW phase (e.g., adaptive devices, interpreter, etc.)?    Yes      No      If Yes, please explain:  								
•	Are there any medical conditions that would pose a concern with the Student’s BTW instruction (e.g., epilepsy, color blindness, etc.)?     Yes      No      If Yes, please explain:  								
•	Is the Student taking any medications that may affect his/her ability to drive a motor vehicle safely?                                                        Yes      No      If Yes, please explain:  										
•	Is the Student’s visual acuity at least 20/40 corrected?	     Yes      No      
•	In the last six months, has the Student had a fainting spell, blackout, seizure, or other uncontrolled loss of     consciousness?                           Yes      No      
•	In the last six months, has the Student had a physical or mental condition which would affect 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.
Date:  			Student Signature:										
Date:			Parent/Legal Guardian Signature:  			            	   				  
Date:  			FAMILY DRIVING SCHOOL:           	                 		Owner/President      	                                       Provider Name		        Provider                                                                                                                        Signature of Provider Owner                                  Title)  
FAMILY DRIVING SCHOOL LLC                                      DATE                                                        OWNER	
VISION TEST
SCREENING TEST
CIRCLE RESULTS

Pass                                                                                                       Fail	
I,		have been administered a vision screening test on		
	(SIGNATURE OF STUDENT NAME)		(DATE)	
by		and received a visual acuity score of at least 20/40 corrected.	
	(INSTRUCTOR NAME)			
	Payment Vision  amount: 00.00	Date(s):	Type: