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
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 | |
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South Dakota Safety Council 1108 N. West Avenue, Sioux Falls All classes held from 12:30 p.m. – 5:00 p.m May 10 ______ June 7 ______ July 26 ______ August 9 ______ |
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 May 10 ______ June 7 ______ July 26 ______ August 23 ______ |
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 |
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Credit card payment: _____ Visa _____ MasterCard _____ American Express |
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Card Number: __________________________ Exp. Date _____/_____ Name on Card:_________________________________________ |
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Contact the South Dakota Safety Council at
sdsc@southdakotasafetycouncil.org
or phone 605-361-7785 or 1-800-952-5539.