Express Driving School
25900 May St. (office)
68935 Gateway Dr., Suite B (classroom)
Edwardsburg, MI 49112
(269)663-3254 office & fax
School Certification #________________
Program #_________________________
Office Hours: M-F
8:00 a.m. to 5:00 p.m.
ENROLLMENT FORM
Please print the following items.
FULL NAME: ____________________________________________________________
Last Name
First Name
Middle
HOME ADDRESS: _______________________________________________________
CITY: _________________________ STATE: ____________ZIP CODE: _____________
BIRTHDATE: _________________________ VERIFIED BY BIRTH CERTIFICATE
AGE AS OF TODAY: ___________________AGE ON 1st DAY OF CLASS__________
HOME PHONE: ________________________CELL PHONE: _____________________
PARENT/GUARDIAN’S NAME: ____________________________________________
PARENT/GUARDIAN’S HOME ADDRESS: __________________________________
PARENT/GUARDIAN’S EMAIL ADDRESS: __________________________________
ALL CONTRACTS:
A. The driving record of each individual instructor is available for review upon
request
B. Notice: This school is required to be licensed by the Michigan Department of
State, Program Operations Division. If you have a complaint which you cannot
settle with this school, write: Michigan Department of State, Driver Programs
Division, Lansing, Michigan 48918. Completion of driver training instruction
does not guarantee qualification for a driver’s license.
SEGMENT (IN ADDITION TO ABOVE)
A. Express Driving School will conduct the behind the wheel instruction in a dual
controlled automobile, fully insured, covering each student enrolled in the
program.
B. The student must be at least 14 years/8 months of age by the beginning of class
(verification by birth certificate required).
CLASS DATES:
The class Dates you are registering for are-
FEES: Course-
Segment I
Hourly Lessons-
$350
($325 if you sign up with a partner)
$30/hour
Fees may be paid using the following payment methods:
Cash, Check, Money Order
(Checks and money orders should be made payable to “Express Driving School”)
$100 Deposit Due at time of enrollment/registration. Balance due 7 days prior to start of class.
-Class size is limited and enrollment is first come, first served
-Attendance is MANDATORY!
-Passing this course does not guarantee you will pass the State driving exam.
-There are no refunds after you have completed this course.
-$25 cancellation fee per student if notice is received less than 10 days prior to class start date.
-Refunds to students dropping during the class are: 75% First 3 days of class; 50% first 6 days
of class; no refunds after 6th day of class.
PROGRAM DESCRIPTION:
Segment I -
6 hours on-the-road driving instruction
24 hours classroom instruction
Express Driving School will provide a minimum of 24 hours of classroom instruction, 6 hours of
behind-the-wheel (BTW) instruction, and 4 hours of observation time. 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.
Hourly Lessons -
Private lessons with instruction provided as needed by the student
NOT required to receive state license.
Attendance is MANDATORY for all scheduled hours. Make-up days may be scheduled at the
discretion of the Drivers Education Instructor when necessary.
You must have a minimum of 222 points to pass the class. Points are broken down as follows:
23 Chapter Tests in Text @ 10 points/test=
3 Assessment Tests from Text @ 20 points/test=
8 Chapter Tests in W.E.D.M.K. @ 10 points/test=
230 points
60 points
80 points
Total Possible Points=
370 points
On the State Segment I Knowledge Test, you must score at least 64 questions correct out of
80 to pass the test.
PLACE OF INSTRUCTION:
All classroom instruction takes place at 68935 Gateway Dr., Suite B, Edwardsburg, Michigan
Students must arrive for their scheduled class on time and must be picked up by their parent or
guardian after the class on time, unless other pick-up/drop-off arrangements have been made
with the instructor.
On-the-road driving instruction will start and end at 68935 Gateway Dr., Suite B, Edwardsburg
Students must arrive for their scheduled driving time on time and must be picked up by their
parent or guardian after their driving time on time, unless other pick-up/drop-off arrangements
have been made with the instructor.
Does this student require any special accommodations to participate in the classroom (Test being
read to him/her, an interpreter, seating arrangements, etc.)? Yes_______ No________
If yes, please explain_____________________________________________________________
Is there any physical condition that would affect his/her ability to perform the driving
maneuvers? Yes_______ No________
If yes, please explain_____________________________________________________________
Are there any medical conditions that would pose a concern (epilepsy, asthma, color blindness,
hearing loss)? Yes________ No________
If yes, please explain_____________________________________________________________
In the last six months, has the student had a fainting spell, blackout, seizure, or other loss of
consciousness? Yes________ No________
If the answer is “yes” then, for the student to continue, you must provide a letter, signed by the students
physician indicating that the condition which cause the episode, was a “one-time” occurrence and would not
occur again/or prevent the student from safely operating a motor vehicle.
Is the student’s visual acuity 20/40 or corrected to at least that? Yes_______ No________
EMERGENCY CONTACT: _________________________ PHONE:
______________________
____________________________________
STUDENT SIGNATURE
____________________________________
PARENT/GUARDIAN SIGNATURE
____________________________________
SCHOOL REP SIGNATURE
____________________________________
TODAY’S DATE
____________________________________
AMOUNT PAID TODAY
___________________________________
PAYMENT METHOD (cash/check/m.o.)
PARENT/GUARDIAN WAIVER
I, ____________________________, parent/guardian of _____________________________,
a student of Express Driving School, give my expressed written permission to allow my child,
listed above, permission to ride alone in the Drivers Education vehicle with the Drivers
Education Instructor.
___________________________________
STUDENT SIGNATURE
____________________________________
PARENT/GUARDIAN SIGNATURE
___________________________________
SCHOOL REP SIGNATURE
____________________________________
TODAY’S DATE