Virtual Online Texas Youth Tobacco Awareness Program
REGISTRATION FOR VIRTUAL ONLINE CLASS
(SSL technology protects your information)
Select Class:
May 21, 23, 28, 30, (7p - 9p), 2024
FIRST NAME:
MIDDLE NAME:
LAST NAME:
BIRTH DATE:
GENDER:
Select Gender >>>
Male
Female
Enter ID: drivers license or social security number. If you have no ID, enter "0":
ID:
Enter court (examples: Mesquite Municipal Court, or Judge Joe Smith, Pct 1, Pl 2):
COURT:
CAUSE/CASE NO:
With the information you submit, we will prepare your registration paperwork. Any student under 18 on first class date must have parent or guardian "signed" authorization on right:
When you have completed all fields, press "submit," or "reset" will clear all fields:
We will text you information about how to prepare for your first class.
ADDRESS 1:
ADDRESS 2:
CITY:
STATE:
ZIP:
IMPORTANT:
Send my certificate of completion to the above address.
NOTE: We cannot send certificates to court.
Do not send my certificate of completion to the above address. Send it to this address:
CELL PHONE
:
EMAIL:
Optional: If we cannot reach you, contact:
NAME:
PHONE:
Below only required if participant will be under 18 years of age on first day of above referenced class.
I, his/her parent or guardian, authorize participant to attend the above referenced class:
My name:
My relationship to participant:
