Enrollment Information

Thank you for contacting Cascade Circle DUI Program. Please fill out the following questions that will be needed for your enrollment. Also please take some time to take a look at our website to familiarize yourself with some of the information that will be needed by you to be sucessful in the program.

We will be reaching out to make an appointment for you shortly.

Thank you

CCI Staff

How would you like to attend your sessions? Live Virtual Service "ZOOM" or In-Person at the Redding office?*

First*

Middle*

Last*

Suffix*

Mailing Address*

City State Zip*

Phone Number*

Email*

example@example.com

DOB*

Drivers License*

Have you ever attended at Cascade Circle in the past?

How many DUIs do you have?*

Violation/Arrest Date-NOT Conviction date*

Date

Length of Program*

Where did you go to Court?*

I verify the above personal information is correct. I verify I have read and understand the information provided to me on the Informed Consent and Agreement document regarding my DUI program enrollment. I am aware in some instances the DMV-MAU or court may later amend my program length and in all cases, I am financially responsible for all DUI program services received. "A 'Transfer In' fee of $135.00 may be incurred if there is a change to the length of the program in which you are or were initially enrolled."

CLIENT INITIAL*

Participant Signature*

Date*

Date