« All Events December 17 – 20 Registration Rossford Location 3 Days March 1 @ 8:00 am - December 7 @ 5:00 pm September 24 – 30 Registration Maumee Location 6 Days » 3 Day DIP Program * Maximum 25 People Intake forms - December 17 - 20 Registration Rossford Location 3 Days "*" indicates required fields EmailThis field is for validation purposes and should be left unchanged.CLIENT INFORMATIONName* First Last Email* Date Registered:*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Program Date:*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex*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 INFORMATIONName* First Last Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code LEGAL INFORMATIONOrdering Court:*Case Number*Breathalyzer Results:*Attorney:*Drivers License Number:*State:*PAYMENT INFORMATION ALL FEES ARE NON-REFUNDABLEMy payment of:* $550 | 72 Hour DIP Shared Room $695 | 72 Hour DIP Private Room $940 | 6 Day DIP Shared Room $1220 | 6 Day DIP Private Room Check out will come after registration.Consent* I agree to the privacy policy.CANCELLATION POLICY A 48-hour cancellation notice is required to change registered dates of attendance. If 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 $100 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.Client Signature* First Last Cancellation PolicyA 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.Consent* By checking this box, you acknowledge that you have read, understood, and agreed to all information, policies, terms, and conditions contained within this form, and certify that all information submitted has been completed truthfully and to the best of your knowledge and ability.By typing your full legal name below and submitting this form, you acknowledge and agree that your typed name constitutes your electronic signature and is legally binding to the fullest extent permitted by applicable law. You certify that you have read, understood, and agree to all policies, terms, conditions, waivers, and procedures associated with this registration and participation. You further affirm that all information and documentation provided through this online form has been completed truthfully and to the best of your knowledge and ability. You understand and acknowledge that additional paperwork, signatures, acknowledgments, or verification of information may be required in person on the day of class or participation, and you agree to complete any such required documents at that time.Name as Signature* First Last Add to calendar Google Calendar iCalendar Outlook 365 Outlook Live Details Start: March 1 @ 8:00 am End: December 7 @ 5:00 pm Event Category: 3 Day
