Portland Driving Academy, Inc. – Segment 1 Registration Form

 

 

Student Name: First_________________________Middle_______________________Last_____________________________________

 

Address: Street________________________________________________City__________________Zip Code_____________________

 

Home Phone: _____________________________Birth Date: ________________ VERIFIED BY BIRTH CERTIFICATE - Student must be 14 years and 8 months by the first day of class

 

Parent/Guardian Name: __________________________________________Phone:______________________________

 

Emergency Contact: _____________________________________________Phone:______________________________

 

  1. Does the student require any special accommodations to participate in the classroom phase (test being read to him/her)?

Yes______   No________

 

  1. Does the student require any special accommodations to participate in the behind-the-wheel phase?

Yes______   No________

 

  1. Is the student taking any medications that may affect his/her ability to drive a motor vehicle safely?

Yes______   No________

 

  1. 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: _______________________________________________

 

  1. Is the student’s visual acuity at least 20/40 corrected?

Yes______   No________

 

  1. In the last six months, has the student had a fainting spell, blackout, seizure, or other uncontrolled loss of consciousness?

Yes______   No________

 

  1. In the last six months, has the student had a physical or mental condition which affected the ability to drive 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.

 

____________________________________________    ______________________________________                ___________________

Parent Signature                                                                        Student Signature                                                          Date

 

___________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________

 

 

Parent Waiver for One Student Drive

 

Please note: Signing below is voluntary. If this waiver is not signed, your teen will not be able to drive if no other student is available to ride along.

 

I give permission for my teen to receive behind-the-wheel instruction with an instructor from Portland Driving Academy, Inc. and do not require additional students to be in the car while my son/daughter receives instruction.

 

 

Parent/Legal Guardian Signature____________________________________________Date_____________________________

 

© 2007 Portland Driving Academy, Inc.