Underage Drug/Alcohol Accountability Program (UDAAP) Registration Form
The information on this form will be kept confidential and will be used only as a part of your educational program.
Today's date
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/
Month
/
Day
Year
Date
Which class are you signing up for?
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8-hour alcohol class $175 (FIRST OFFENSE ALCOHOL ONLY)
12-hour drug class $265 (SUBSEQUENT OFFENSE OR DRUG OFFENSE)
I understand that if I am required to take the 12-hour course because this is a 2nd offense alcohol violation or a 1st offense drug violation, the course will take place over two (2) days. Contact our office for more information and dates available.
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Yes
No
Please select your class date:
*
Please Select
Sat. 11/30/2024
First Name
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Middle Initial
*
Last Name
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Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
SSN (Last 4 Digits ONLY)
*
Sex:
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Male
Female
Race
*
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email (PARTICIPANT EMAIL, NOT PARENT EMAIL)
*
example@example.com
Referred By:
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City of Kenosha Municipal Court
Kenosha County Circuit Court
Other
1st Court Date
*
-
Month
-
Day
Year
Date
Next Court Date (return date)
*
/
Month
/
Day
Year
Date
Living Arrangement (CURRENT)
*
Living with Parents
Living in Dorm (at school)
Living in Private Residence WITHOUT Parents (apartment/fraternity/sorority etc.)
Other
Employment Status (CURRENT)
*
Full-Time Student
Part-Time Student
Employed Full-Time
Employed Part-Time
Unemployed but looking
Unemployed, not looking for work/disabled
I have Completed High School (HSED or GED)
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Yes
No
Highest Grade I have Completed (number only)
*
Have you received any prior alcohol or other drug offenses/citations in any city/county/state?
*
Yes
No
If Yes, Please Explain:
Have you received any prior alcohol or other drug offenses/referrals/citations either through school, or athletics, etc.?
*
Yes
No
If Yes, Please Explain:
Have you received any prior education, counseling, or treatment specific to your own alcohol and/or other drug use?
*
Yes
No
If Yes, Please Explain:
I understand that I MUST contact the Hope Council within 48 HOURS at (262) 658-8166 to make my payment in order to complete my registration.
*
Yes
No
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Upload a copy of your citation:
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Signature
*
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