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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 to the following:

    I am the individual named above, and I acknowledge that I have the right to contest or mitigate the infraction(s) listed in the citation provided. However, instead of exercising either of those options, I choose to voluntarily participate in the Traffic Safety Program. I understand that my participation applies solely to the traffic citation listed above, and any other infractions I may have received must be addressed separately with the Court.

    I agree that I committed the traffic infraction listed on the citation above. As a participant in the Traffic Safety Program, I agree to the following conditions:

    1. I will complete the DEFENSIVE DRIVING class within twenty days from today.

    2. I will pay a non-refundable $150 registration fee. 

    3. I understand that upon completing the class, the Prosecutor's office will move to dismiss this infraction.

    4. I understand that if I fail to complete the class within twenty days, the Court will find that the traffic infraction was committed without further notice or hearing, and the finding will be reported to the Washington State Department of Licensing.

    I certify under penalty of perjury under the laws of the State of Washington that the above statements are true and correct.

22. Payment Confirmation Number*
    You must pay for the class and receive a confirmation number before you will be registered.
24. Classes
    -- Select One --Traffic Safety ProgramTraffic Safety Program (Spanish)

    Please select which class you would like to register for.

25. Class Preference*
    -- Select One --ONLINEIn Person

    Select the option please.
27. Class Enrollment Agreement

    By completing this registration form I understand that the $150.00 class fee is non-refundable. If I am unable to attend the class for any reason I must contact the Program Coordinator, Irene Neimi via phone at 509-574-1811 or by email at irene.niemi@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 $150.00 fee once more.

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

    This field is not part of the form submission.

31. Submit

* indicates a required field