July 23 – 29 Registration Rossford Location 6 Days

April 14 @ 8:00 am - July 15 @ 5:00 pm

6 Day DIP Program
* Maximum 25 People

Intake forms - July 23 - 29 Registration Rossford Location 6 Days

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

CLIENT INFORMATION

Name

First Last

Date Registered:

Program Date:

Age

Date of Birth

Sex

SSN

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Prescribed Medications:

All prescription medication is required to be surrendered in the original, labeled, containers which will be made available to you at the prescribed times. Any over-the-counter medication must be in a new, unopened package (i.e. aspirin, cold tablets, vitamins).

Non-Prescribed Medications:

Special Needs Diet:

Known allergies/Food reactions:

Primary Care Physician:

Pregnancy Status:

Smoker:

Prior Alcohol/Drug Treatment

When/Where

EMERGENCY CONTACT INFORMATION

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

LEGAL INFORMATION

Ordering Court:

Case Number

Breathalyzer Results:

Attorney:

Drivers License Number:

State:

CHECK ONE:

2-Point Credit; You must have between 5-11 points on your record at time of course

12-Point Suspension; you must have received your notice from the state

PAYMENT INFORMATION ALL FEES ARE NON-REFUNDABLE

My payment of:*

$550 | 72 Hour Drivers Intervention Program – Shared Room

$695 | 72 Hour DIP Private Room

$940 | 6 Day DIP Shared Room

$1220 | 6 Day DIP Private Room

Paytrace*

Card Number Expiration Month Expiration Year Security Code

Client Signature*

First Last

Cancellation Policy

A 48-hour cancellation notice is required to change registered dates of attendance or you fail to attend a scheduled weekend program, or must change your scheduled weekend after the 48-hour time period has expired the registration fee will not be refunded and there will be a $50 rescheduling fee. We do understand that unusual circumstances arise which may have prohibited you from canceling your appointment or program with advance notice. Please discuss these situations with us and under certain circumstances, we may determine to waive the rescheduling fee. Please note, if you do need to reschedule, this may be done ONE TIME ONLY. I give Giving All Back DIP permission to charge my credit card for the program and amount selected above. I understand that my payment information will be kept confidential. By signing I also acknowledge and understand the above noted cancellation policy.

Name as Signature*

First Last

Details

Start: April 14 @ 8:00 am
End: July 15 @ 5:00 pm
Event Category: 6 Day

July 23 – 29 Registration Rossford Location 6 Days

Intake forms - July 23 - 29 Registration Rossford Location 6 Days

CLIENT INFORMATION

EMERGENCY CONTACT INFORMATION

LEGAL INFORMATION

PAYMENT INFORMATION ALL FEES ARE NON-REFUNDABLE

Cancellation Policy

Details

Address

Call Us

Email Us