** PREVIEW **

Segment 2– CONTACT SHEET

Date Of Class
Time

Student Name
Student First Name
Student Last Name
Student Middle Name
Age
Date Of Birth
Issued Date of Level One License
Address
City
Zip
Home Phone
Work Phone (Parent/Guardian)
Parent / Guardian's Name
Home Phone

Provisions:

Advanced Driving Academy will provide a total of 6 hours of classroom instruction by certified instructor. Classroom instruction shall not exceed 2 hours per day.


Yes N0
Yes N0

I, the undersigned, agree to the following:

Terms/Conditions:

  • Yes N0
  • Yes N0

Fee/Refund Policy:

Dropped Program- Yes N0
Rescheduling of a Program- Yes N0
Late/No-Show of A Classroom Session - Yes N0
Late/Missed Classroom Session - Yes N0

NOTICE - This provider is required to be certified by the State of Michigan. If you have any 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 driver license

Date of Contract

I agree to Terms & Conditions