Alcohol awareness class and defensive driving class for minors.

P.O. Box 614 - Arlington, TX 76004 - (817) 654-9722 - Fax: (817) 446-6253

Submit by email or print and mail

First Name: ___ Last Name: ___Middle Initial: ___
Mailing Address: City: State: ___
Zipcode : Phone Number: Date of Birth:
Email Address:

Court Information: (write insurance instead if applicable)
City in which ticket was issued: Type of class (alcohol or tobacco)
Date of class you will be attending:
Judge's Name:
Court Address:
Docket-Ticket #:


 

Name:__________________________________________________________
           Last                                                First                                          M.I.

Local Mailing
Address:________________________________________________________
               Street                                                 City/State/ZIP

Phone Number: (   )____________     Sex: __________Male __________Female

Date of Birth:__________Age:_______ Driver's License#:__________________

High School/College Classification:___________Social Security#:____________
Court Information:
(if applicable)
(write "Insurance"
if taking for ins.)		 City:______________________________________________
Judge's Name:______________________________________
Address:__________________________________________
Docket/Ticket#:_____________________________________

Confidentiality and Attendance Statement
(PLEASE READ CAREFULLY)

I understand that:

1) Information about me and my progress in the alcohol education program may be used for research purposes (without identifying me) and may be shared with the court. I hereby authorize such use with the further understanding that this information will otherwise be held confidential and not released to other individuals or agencies for any reason without my signed consent. This consent may be revoked at any time, but is necessary for class participation.
2) If I am unable to attend on dates for which I am registered, I must notify Brenda Postert, (Director/Instructor), no later that 5 days before the first class date or I will have to repay to be transferred to another class. Such notice may be given by phone.
3) Tardiness or absence from any class will result in my being dropped from the course and loss of my registration fee.
4) I must complete a written exam with a minimum score of 70% to receive a certificate.
5) I must complete an invidual exit interview within 14 days of course completion. If I fail to complete my exit interview at the time scheduled, I must pay a $10 rescheduling fee.
6) I understand it is MY sole responsibility to notify the court of successful completion of the course by presenting my completion certificate to the court or by any other means the court desires.

I have read and will comply with all items herein and attend class on (Date)

Date_________________________Student Signature_________________________________
Date_________________________Parent's Signature (if 16 or under)____________________
*Persons under age of 16 must be accompanied by a parent or legal guardian at time of registration.