DUI School Online Registration

Personal History
First Name*
Last Name*
Middle Initial
Maiden Name
Email*
Street Address*
City*
State*
Zip Code*
Date of Birth*
Month
Day
Year
Age*
Sex*
- Male
- Female
Race*
- Black
- White
- Other
Social Security Number*
Phone*
Work Phone
Alternate Phone
Are you a veteran?*
- Yes
- No
Employer Name
Employer Street Address
Employer City
State
Employer Zip Code
Marital Status*
- Never Married
- Married
- Divorced
- Separated
- Widow(er)
Emergency Contact*
Emergency Contact Relationship*
Emergency Contact Phone*

Agreement to Participate
I understand and agree to abide by the following rules and regulations in order to graduate from the Davison County Sheriff’s Office Safety Center. I understand that part of the program involves assessing and identifying individuals who might have alcohol/drug related problems.

1. NO BUSINESS OF ANY NATURE (OFFICE OR CLASSROOM) WILL BE CONDUCTED WITH ANYONE WHO IS USING ALCOHOL/DRUGS IN ANY AMOUNT.
- (a.) I agree to abstain from all drugs/alcohol until I graduate from this program, except medication prescribed by a licensed physician.
- (b.) I agree to come to class (or the office) without any alcohol/drugs in my system. I hereby agree to consent to examination by the Davidson County Sheriff’s Office Safety Center staff if I appear to be under the influence of alcohol/drugs.
If I come to the Safety Center under the influence I may be required to complete additional education or treatment requirements to graduate. And my results be reported to my Probation Officer.

2. ATTENDANCE
- (a.) I agree to attend all classes as scheduled.
- (b.) I agree to arrive on time for classes (no one will be admitted to class late) and cooperate with instructors and other Davidson County Sheriff’s Office staff members.
- (c.) I agree to contact the office within a week to reschedule any class(es) missed.
- (d.) I agree to comply with the dress code policy while I am conducting business with the DUI School.
- (e.) I agree to not use a cell phone while in the building as this may violate laws of confidentiality.
- (f.) I agree to pay a $20 re-scheduling fee for any absence. (You will only be allowed one reschedule with no penalty of $20.)
- (g.) All class fees must be paid in full prior to taking the class. ** PLEASE NOTE: ONLY MONEY ORDERS ARE ACCEPTED.
I agree to accept responsibility for any and all violations of this agreement which will be promptly reported to the Court of jurisdiction.
Acknowledgement of Agreement to Participate:*
I HAVE READ AND AGREE TO ALL OF THE ABOVE.

Certificate of Completion Policy
1.) In order to receive a certificate of completion you must pay all school fees, attend all classes. If you do not complete this within one year you will be required to update your paperwork, attend classes, and be reassessed.

2.) If you are referred to Level III we must receive documentation from the treatment provider that you have completed all treatment requirements as determined by the Clinical Staff of the Safety Center and listed on you Placement Plan Agreement.

3.) Please be advised that if you come to the office or classes under the influence of alcohol of other drugs or if you are re-arrested for an alcohol or drug related offense you will not be issued a certificate of completion until you update your paperwork and interview with a counselor to determine what steps you must take to qualify for a certificate of completion. This office can deny a certificate of completion if you continue to present a serious risk to public safety.

4.) If you need a “Status Letter” for a probation officer or for court, one will be provided to you at no charge. A “Status Letter” will not meet the driver’s license reinstatement requirements of the Department of Safety.

5.) If you are re-arrested for DUI, but it is dismissed, we will issue the certificate of completion as soon as you meet the requirements of #3.

6.) If you are convicted of a new DUI you will be referred to the Safety Center’s Level III program. You must complete all of Level III requirements to receive a certificate of completion.

7.) If you lose your certificate of completion and require a duplicate certificate, the Safety Center will run a new arrest history, if it has been more than a year. If you have not been re-arrested for another alcohol related offense you will be eligible for a duplicate certificate. You will have to pay a $10.00 for the review of your record and the new certificate.
Acknowledgement of Certificate of Completion Policy:*
I HAVE READ AND AGREE TO THE ABOVE.

Services Provided for Fees
1. SERVICES PROVIDED:
- a. I understand that I am enrolling in a state licensed DUI School and that the Safety Center offers the 12 hour PRIME for Life Program.
- b. I understand that a state licensed DUI School may require me to complete an assessment and report the findings to the client and the probation officer or the referring court.
- c. I understand that state licensed DUI Schools are required to make treatment and mental health referrals for the client when the assessment finds clinical support for such a referral.
- d. I understand “a judge may require anything reasonably related to the offense as a condition of probation or bond” and a referral to substance abuse treatment may be required as condition for probation or bond.
2. FEES FOR SERVICES:
** PLEASE NOTE: ONLY MONEY ORDERS ARE ACCEPTED.
- a. I understand that the fee for the PRIME for Life Program is $140.00 which must be paid in full at the time of registration.
- b. I understand if my arrest occurred outside the State of Tennessee, I will be charged $240.00. An assessment will follow the completion of classes and is mandatory for all out of state offenders. The $100.00 assessment fee is included in the $240.00.
- c. All Out of State clients must provide referral paperwork from the court.
ADMINISTRATIVE REPORTS
I hereby authorize necessary reports required by the Referring Court to be released to the Judges, Probation officers, Court Officers, and the District Attorney’s Office.
Acknowledgement of Services Provided for Fees:*
I have read and agree to all of the above.

Release of Information Authorization, Payment Information & Consent
Payment is due upon arrival. Other payment information can be added here...
Do you have a fee waiver?*
- Yes
- No
Please provide any available information related to your fee waiver.
Please upload any court documents related to your fee waiver.
Drop files here or

Max. file size: 1 GB.
If you were arrested outside of Tennessee, please upload any relevant court documents.
Drop files here or

Max. file size: 1 GB.
Consent to release of information to attorney.*
I hereby authorize the Davidson County Sheriff’s Office Safety Center to release information regarding my status at the Safety Center to my Probation Officer and the Court having jurisdiction. I understand that this information will be used to determine my compliance with the orders of the Court and the conditions of my probation.
PLEASE IDENTIFY YOUR ATTORNEY IF YOU WANT TO GIVE THIS OFFICE PERMISSION TO RELEASE INFORMATION TO HIM/HER:*
Consent to release of information to family member.
IF YOU WANT TO GIVE THE SAFETY CENTER STAFF PERMISSION TO RELEASE INFORMATION TO ANY INDIVIDUAL (FAMILY MEMBER OR FRIEND) PLEASE IDENTIFY THE PERSON (S) BY NAME:
IF YOU WANT TO GIVE THE SAFETY CENTER STAFF PERMISSION TO RELEASE INFORMATION TO ANY INDIVIDUAL (FAMILY MEMBER OR FRIEND) PLEASE IDENTIFY THE PERSON (S) BY NAME:
Please consent to the following. All fields below are required!
Please acknowledge:*
I understand that all intake information is held confidential and protected by (42-CFR, Part 2) Federal Laws governing the confidentiality of alcohol/drug treatment records. Without this release the Safety Center is not allowed to discuss your case, schedule appointments or conduct any business with anyone other than yourself.
Please acknowledge:*
I understand that this Federal Law requires that I protect the confidentiality of other people in the program.
Please acknowledge:*
This authorization may be revoked at any time by my written statement, and is automatically revoked at the end of my probationary period of the charge which I am currently being referred for education and/or treatment.
Name
This field is for validation purposes and should be left unchanged.

Step 1 of 11

Personal History

Agreement to Participate

Certificate of Completion Policy

Services Provided for Fees

Concerning Your Current Alcohol or Drug Related Arrest

Alcohol/Drug Use History

Prime for Life A Risk Reduction Program (Pre-test)

MAST

C.A.S.T.

DAST (Drug Abuse Screening Test)

Release of Information Authorization, Payment Information & Consent