ENROLLMENT INFORMATION

DUI PROGRAM ENROLLMENT INFORMATION-INFORMED CONSENT & AGREEMENT
Thank you for contacting Cascade Circle DUI Program. Please fill out the following questions that will be needed for your enrollment. We do request a $200.00 downpayment at time of enrollment appointment. 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.

Please do not submit more that one form. Duplications will slow down the process.

We will contact you to schedule an appointment within 72 business hours.

Thank you
Today's Date*

MonthDayYear
Date
Client Name*
FIRST - MIDDLE - LAST - SUFFIX
Address*

Address

Street Address Line 2

City & StateState / Province

Zip
Phone*
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Age:*
Driver's License or ID Number*
How many DUI's do you have*
Have you attended our program before*
Are you reinstating into our program after termination*
What is the date of your most recent DUI violation*

MonthDayYear
Date
What town did you receive your DUI in*
What length of program have you been ordered to take*
If you want court to be notified you will need to provide court paperwork do you want court notified*
Please email us your court paperwork. If we do not have it we cannot notify the court.
Would you like to attend Live Virtual Service Zoom or InPerson*
Notes
I acknowledge that, in some cases, the DMV-MAU or the court may amend the required length of my program. I understand that I am financially responsible for all DUI program services I receive. Additionally, Client Initial:I understand that a Transfer-In fee of $135 may apply if there is a change to the length of the program in which I am or was originally enrolled. I verify that the information provided above is accurate. I confirm that I have read and understand the Informed Consent and Agreement document related to my DUI program enrollment.
Signature*

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