Course Registration Form

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?

Date

Preferred Class Date*

Where did you have your evaluation completed? *

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.I understand that ADIS is considered an educational class, and insurance will not cover the cost.I understand that by registering for this course that I was assessed at ASAM level 0.5 (ADIS).I understand that Gateway Counseling Services needs a court referral to report completion.I understand that a release of information is required to send any information to anyone including the DOL, courts, probation, etc.

Signature

Class Payment*

ADIS CLASS

$115.00 Quantity

Total

$0.00

ADIS Class Registration Form

Important Information: