SEGMENT TWO CLASS REGISTRATION
February 10, 11, 12; Monday, Tuesday, Wednesday: 4pm-6pm
Class Dates
First Name
*
Middle Name
*
Last Name
*
Birth Date
*
/
Month
/
Day
Year
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When did you get your Level 1 License?
*
-
Month
-
Day
Year
Date Picker Icon
Where did you take Segment 1 class?
*
Mr. R’s Driving School
Central Driving School
Lansing Area Driving School (@Lansing Catholic)
Knox Driving School
C & C Driving School
Mr. Bentley’s Driving School
Driving Right-Bath
Driving Right-East Lansing
Driving Right-Haslett
Driving Right-Laingsburg
Capital Area Driving School
Preston Driving School
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Attended
*
Haslett
Williamston
Okemos
East Lansing
Bath
Perry
Laingsburg
Lansing Catholic
Lansing Christian
Webberville
Fowlerville
Dansville
Mason
DeWitt
St. Johns
Lansing Eastern
Lansing Waverly
Lansing Sexton
Lansing Everett
Grand Ledge
Charlotte
Eaton Rapids
Potterville
Owosso
Leslie
Ingham Academy
Nextech Academy
Homeschooled
Other
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Parent/Guardian E-mail
*
This e-mail will receive a confirmation receipt.
Student or Secondary E-mail
This e-mail will NOT receive a confirmation
Gender
Female
Male
Comments or Extra Information
Future Info From Mr.R's
Yes, I want to receive updates via e-mail!
Payment
*
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Pay on the first day of class
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SEGMENT TWO CLASS
$
60.00
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