Registration Form

Please check Schedules and Registration Procedures
for the town and class you wish to take.


Registration Form for Austin


________Adolescent Tobacco Cessation (8 hours)                        $65.00


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 _____________________________________________________________