Chance2Change: Pre-registration (DWI/DOEP/Alcohol Minors/Court Ordered)

Pre-Registration Form (DWI/DOEP/Alcohol Minors & other State Programs)

Thank you for your interest in Chance2Change. Please fill out and submit the form below and we will contact you within 24- to 48-hours to confirm your enrollment. We look forward helping you!
Participant Information
Participant Name/ Nombre*

First Name/NombreLast Name / Apellido
Participant Email Address/ Direccion de Correro Electronico*
example@example.com
Participant Address/ Direccion de casa*

Street Address

Street Address Line 2

City/ CuidadState / Province/ Estado

Postal / Zip Code/ Codigo PostalCountry
Phone Number/ Numero de telefono*

Area CodePhone Number
Date of Birth/ Fecha de Naciemiento*

MonthDayYear
Date
Age/Edad*
Gender/ Genero*

MaleFemale
Type of Service/ Servicio Necesario*

DWI- Education 12 hoursDWI- Intervention (repeat) 30 hoursDrug Offender Education Program (DOEP) 15 hoursAlcohol Education Program for MinorsMarijuana ClassesIndividualSubstance Abuse EvaluationVictim Impact
Race/Ethnicity/ Raza Etnia*
Case/Cause #/ Numero de Caso (State requirements for these programs. Please contact your local counties/courts/officers to obtain this number)*
County of Conviction/Or case filed/ Condado de condena*
State DL/ID # Mandatory for Certificate if no license input (12345) Numero de Licencia ( si no tiene entre 12345)*
English or Spanish
Name of attorney, officer, judge or referring person/agency/ Nombre de person/agencia de referencia, o nombre de abogado o oficial
Referring person/agency phone number/ Telefono de referencia

Area CodePhone Number
Referrer's Email/ Direccion de Correro Electronico de person de referencia :
example@example.com
Preferred Days for Sessions/ Dias preferidas*

Day/ DiaEvening/ NocheWeekends/ Fin de semana
Preferred Location for Sessions

Oak Cliff/ DallasPleasant Grove/ DallasGrand Prairie / DallasCollinDentonTarrantHoustonEl PasoSan AntonioOther
Additional Information (Please include date and time preferences for sessions) Informacion que quiera dejar:
Payments can be made via/ Pagos en forma:

No REFUNDS

Zelle: 214-772-0226

ApplePay:214-772-0226

Venmo:@Chanceto-Change

Paypal: paypal.me/CLchance2change
Should be Empty:

Pre-Registration Form (DWI/DOEP/Alcohol Minors & other State Programs)

Participant Information