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: 605-361-7785/800-952-5539
Choose class location and date:

School of Mines
Classroom Building Room 107
Address: 510 East St. Joseph Street, Rapid City, SD

All classes held from 12:30 p.m. – 5:00 p.m
June 24, 2017 ______
July 29, 2017 ______
August 26, 2017 ______
September 23, 2017 ______
October 28, 2017 ______
December 9, 2017 ______

Participant information

Last name:_______________________________ First name: ____________________________

Middle Initial:_______________ Date of Birth:______________________

Address: ______________________________________________________________________

City, State, Zip: ________________________________________________________________

Phone: _________________ 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 + tax 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.