South Dakota Safety Council: Class Schedule/Court-Referred Registration Form

Alive at 25 Class Schedule/Court-Referred Registration Form

NOTE: Use this form only if the class participant has been referred by the court system or is taking the class as the result of a violation.

All registrations through South Dakota Safety Council.

Three ways to register:
Mail: South Dakota Safety Council 1108 N. West Avenue Sioux Falls, SD 57104	Fax: 605-361-2156	Phone: Diane at 605-361-7785/800-952-5539

Choose class location and date:
Rapid City Police Department, Crime Prevention Office
Rushmore Mall / 2200 N. Maple Avenue
All classes held from 12:30 p.m. – 5:00 p.m
April 16, 2011 ______
May 21, 2011 ______
June 18, 2011 ______
July 23, 2011 ______

Vermillion
Vermillion Fire Department Training Room / 820 North Dakota
All classes 12:30 p.m. – 5:00 p.m
May 21, 2011 ______
August 20, 2011 ______

Participant information

Last name:_______________________________ First name: ____________________________

Middle Initial:_______________ Date of Birth:______________________

Address: ______________________________________________________________________

City, State, Zip: ________________________________________________________________

Drivers License Number:_________________________________________________________

E-mail address:________________________________________________________________

Case #______________ Docket #______________ Summons #________________

Referring court or agency ____________________________________________

Date referred __________________ Date by which class must be taken __________________

Tuition: Due one week before class. $65 payable to the South Dakota Safety Council, 1108 N. West Ave / Sioux Falls, SD 57104 (checks, money orders, and credit cards accepted).

_____ Payment enclosed: _____ Check _____ Money order
Credit card payment: _____ Visa _____ MasterCard _____ American Express
Card Number: __________________________ Exp. Date _____/_____ Name on Card:_________________________________________

Contact the South Dakota Safety Council at
sdsc@southdakotasafetycouncil.org
or phone 605-361-7785 or 1-800-952-5539.