Course Registration Form

ADIS Class Registration Form

This form registers you for Gateway’s 8-hour Alcohol & Drug Information School (ADIS) class. We’ll contact you after submission to arrange your class materials.
Important Information:

1. If you had your evaluation somewhere other than Gateway Counseling, please bring or send a copy of your assessment results to info@gatewaycounseling.net.
2. ADIS is considered an educational class and insurance will not cover the cost of the class, so payment must be made at the time of registration.
Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Do you have a legal deadline for completing this class?

MonthDayYear
Date
Preferred Class Date
How would you like to receive your class materials?

I will pick them up in person at Gateway.Please mail them to me (Only if registration is at least 3 days prior).
Acknowledgment Checkbox*

I understand this class is non-refundable after registration.I understand that materials must be picked up or mailed prior to the class date.I understand I must receive physical class materials before the class date in order to participate.
Class Payment*
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ADIS CLASS
$115.00 Quantity

Total

$0.00
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ADIS Class Registration Form