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Class Registration Form

2. First Name*

3. Last Name*

4. Middle Initial

6. Address*

8. City*

9. State*

10. Zip Code*

12. Date of Birth*

14. Case Number (if available)

15. Phone Number*

17. Email Address*

19. Payment Confirmation Number*

    You must pay for the class and receive a confirmation number before you will be registered.

21. Classes*
    -- Select One --Traffic School (age:16-24)Defensive Driving School (Spanish)Defensive Driving School (age: 25 & older)Cost Recovery Cost Recovery (Spanish)

    Please select which class you would like to register for.

22. Date of Class*
    Date of Class

24. 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 509-574-1892, 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.

    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 509-574-1892, 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.

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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field