First and Goal Inc.

Cost:
Pre-registration is required $35.00 per class (2 class series) Must be paid in full before or at registration. No refunds after class start dates.
A certificate of completion will be given upon completion of final class

After Completing this form you will be prompted to pay via Credit Card

Date:

Juvenile Court:

Name of School:

Case Number:

Judge Kent Adams - Precinct 4, Place 1 Class Type:

Anger Management

Decision Making

Last: First: MI:

Date of Birth: Gender: Female Male Ethnicity:

What academic year are you?

Grad

Future Career Goal:

Permanent Address:

City: State: Zip Code:

*Preferred Phone:

*Email:

Person to notify in case of emergency:

Name: Relation:

Address if different from above

Street Address:

City: State: Zip Code:

*Preferred Phone:

Please list and explain any known medical conditions:

Are you currently on any prescribed medication? Yes No

If yes, please explain: