Underage Drug/Alcohol Accountability Program (UDAAP) Registration Form

Underage Drug/Alcohol Accountability Program (UDAAP) Registration Form

All information provided is strictly confidential and used for program registration only.
Today's date*

MonthDayYear
Date
Which class are you registering for?*

8-Hour / 1st offense, alcohol only12-Hour / 2nd offense and/or drug citation
I understand that if I am required to take the 12-hour course because this is a 2nd offense and/or a 1st offense involving drugs, the course will take place over two (2) days. Please select from the dates below for the 8-hour course, we will contact you with more information about adding the additional 4 hours.*

YesNo
Please select your class date:*
First Name*
Middle Initial *
Last Name*
Date of Birth*

MonthDayYear
Date
Age*
SSN (Last 4 Digits ONLY)*
Sex:*

MaleFemale
Race*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
EMAIL (Participant, NOT parent/guardians)*
example@example.com
Referred By:*

City of Kenosha Municipal CourtKenosha County Circuit CourtOther
1st Court Date *

MonthDayYear
Date
Next Court Date (return date)*

MonthDayYear
Date
Living Arrangement (CURRENT)*

Living with ParentsLiving in Dorm (at school)Living in Private Residence WITHOUT Parents (apartment/fraternity/sorority etc.)Other
Employment Status (CURRENT)*

Full-Time StudentPart-Time StudentEmployed Full-TimeEmployed Part-TimeUnemployed but lookingUnemployed, not looking for work/disabled
I have Completed High School (HSED or GED)*

YesNo
Highest Grade I have Completed (number only)*
Have you received any prior alcohol or other drug offenses/citations in any city/county/state?*

YesNo
If Yes, Please Explain:
Have you received any prior alcohol or other drug offenses/referrals/citations either through school, or athletics, etc.?*

YesNo
If Yes, Please Explain:
Have you received any prior education, counseling, or treatment specific to your own alcohol and/or other drug use?*

YesNo
If Yes, Please Explain:
Upload a copy of a valid Drivers License or State/Federal (passport) ID card:*

2 MB Maximum File Size
Cancelof
Upload a copy of your citation (ticket):

1 MB Maximum File Size
Cancelof
I understand that registration is not complete until full payment is received. Please select from the following payment options:*

Pay OnlinePay Over the Phone

Pay Registration Fees Online*

UDAAP 8-Hour Class Registration Product Image

UDAAP 8-Hour Class RegistrationIncludes Card Processing Fees

$182.50

UDAAP 12-Hour Class Registration Product Image

UDAAP 12-Hour Class RegistrationIncludes Card Processing Fees

$275.50

Total

$0.00

Payment Methods

Credit Card

Apple Pay

It is the participant’s responsibility to contact the Hope Council within 48 hours to pay the registration fee. Please note: Hope Council staff are prohibited by law from discussing this matter with parents or guardians. The participant must contact the Hope Council directly.

If payment is not received within 48 hours, this registration will expire and you will be required to complete and submit the intake forms again.

You may reach the Hope Council office during regular business hours at (262) 658-8166. If we are unable to answer, please leave a message in the general mailbox and we will return your call as soon as possible.
Signature*

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