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2. First Name*
3. Last Name*
4. Middle Initial
6. Address*
7. City*
8. State*
9. Zip Code*
11. Date of Birth*
12. Driver License Number*
13. State License Was Issued*
15. Case or Ticket Number
16. Email Address*
17. Phone Number*
18. Can we send text messages to your phone?

    1. Yes, I opt in to receiving text messages.
20. Read the following carefully before signing.
    I hereby certify and agree as follows: I am the person named above. I understand that I have the right to either contest or mitigate the infraction(s) I have been charged with in the citation(s) listed above. Rather than exercising either of those options I wish to voluntarily enter into the Traffic Safety Program. I understand that my participation in this program only applies to the traffic citation that I have received and that any other infractions that I may have received will have to be addressed separately with the Court. I agree that I have committed the traffic infraction listed on the citation above. As a participant in the Traffic Safety Program, I understand and agree to the following conditions: (1) I agree to complete the 19-DEFENSIVE DRIVING class through Yakima County Probation Services by thirty days from today, (2) I agree to pay the registration cost of $120.00, (3) I understand that if I complete the class as required that the Yakima County Prosecutor’s Office will move to dismiss the traffic infraction only, (4) I understand that failing to complete the class within 30 days from today, will result in the Court finding the traffic infraction committed without further notice or hearing to me and the Court will report the finding to the Washington State Department of Licensing. I hereby certify under the penalty of perjury under the Laws of the State of Washington that my foregoing statements are true and correct. Signed in Yakima (City), Washington (State) on:
22. Payment Confirmation Number*
    You must pay for the class and receive a confirmation number before you will be registered.
24. Classes
    -- Select One --Defensive Driving SchoolDefensive Driving School (Spanish)Cost RecoveryCost Recovery (Spanish)

    Please select which class you would like to register for.
25. Class Preference*
    -- Select One --ONLINEIn Person

    Select the option please.
26. Date of Class
    Date of Class
    Enter the date you want to take the class. Leave blank if selecting online.
28. Class Enrollment Agreement
    By completing this registration form I understand that the $120.00 class fee is non-refundable. If I am unable to attend the class for any reason I must contact the Program Coordinator, Vita Alvarez via phone at 509-574-1892 or by email at Vita.Alvarez@co.yakima.wa.us, as soon as possible. I am aware that I will only be rescheduled one time. If I miss the rescheduled class for any reason I will be required to pay the $120.00 fee once more.
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field