Underage Drug/Alcohol Accountability Program (UDAAP) Registration Form

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*

MonthDayYear
Date
Which class are you signing up for?*

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.*

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 EMAIL, NOT PARENT EMAIL)*
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:
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.*

YesNo
Upload a copy of a valid Drivers License or State/Federal (passport) ID card:

Cancelof
Upload a copy of your citation:

Cancelof
Signature*

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Should be Empty: