** PREVIEW **

Segment 1– CONTACT SHEET

Start Date
End Date
Time

Student Name
First
Last
Middle
Age
Date Of Birth
Address
City
Zip
Home Phone
Parent/Guardian Cell
Student Cell
 
Same as student address
Parent Address
City
Zip

I, the undersigned, agree to the following:


Provisions: Advanced Driving Academy will provide a minimum 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 in the program. 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.

Terms/Conditions:

  • Yes N0
  • Yes N0
  • Yes N0
  • Yes N0
  • Yes N0
  • Yes N0
Fee/Refund Policy: Yes N0
Rescheduling of a Class - Yes N0
Insufficient Funds Yes N0
Late/No-Show of A Scheduled Drive - Yes N0

Health Statement:

  • Yes N0
  • Yes No
  • Yes No
  • Yes No .
  • Yes No
  • Yes No .

Certification: I certify that the information on this form is true and accurate to the best of my knowledge and by signing this form, I give permission to ADA to use my son/daughter in any form of media (photos, videos, audio, etc.) taken during the program for marketing purposes.


Date of Contract
Driving Waiver: Yes No

I agree to Terms & Conditions


NOTICE - This provider is required to be certified by the Secretary of State. If you have a complaint, which you cannot settle with this provider, write: Michigan Department of State, Driver Programs Division, Lansing, MI 48918.

Completion of driver education instruction does not guarantee qualification for a drivers license