Please check
Schedules for the
town, class, tuition
and registration
instructions
for your classes.
|
- email completed form to us or
- print and fax completed form or
- mail it!
Check the class you wish to take.
________ Alcohol Education Program for MIP (6 hours) $45.00
________Adolescent Tobacco Cessation (8 hours) $65.00
________Drug Offender Education Program (15 hours) $85.00
Your paid tuition guarantees your seat in class. For that reason tuition is non-refundable.
DATES OF THE CLASS YOU WISH TO TAKE: __________________________________
Name___________________________________________ Age __________________
DL or SS#______________________________________ DOB____________________
Street Address___________________________________________________________
City, State, Zip Code_______________________________________________________
Phone number(s)_________________________________________________________
Parent’s Signature, if you are under 16________________________________________
Who referred you? Please state specific court, judge, or probation officer,
if referred for legal reasons _______________________________________________
Payment Options _______________________________________________________
Credit Card #_________________________________ Exp Date________Code______
Name on Card__________________________________________Type of Card______
Email Address __________________________________________________________
Signature _____________________________________________________________
