Pre-Registration Form for  Danger Without Intentions Programs  (If you want to pre-register, you can send it by email as noted below) 
    You can not fill out this form from this page, you will have to do the following in order to fill out this form:


    To send information by email, you will need to do the following:  
    1)  CLICK above on the tool bar:   File
 
   2)  Under FILE click on:                  SEND
    3)  Under SEND click on:                 Page by Email  
       
It will open up you email, FILL OUT the Pre-Registration Form and then just put in our email address into the TO field.    Our  email is:  dwi@gvtc.com

Pre-Registration Form
for :

If you would like to Pre-Register by Email, we will need ALL of the following information filled in for getting registered to attend any of the 3 programs listed below:

1

Mark with "X" which Class you are  Pre-Registering for:

 

 

-  Choices & Consequences

$30 - 3 Hour Program

 

-  Drunk Driving / Victim's Impact Panel

$30 - 3 Hour Program

 

-  Alive at 25 - Young Driver Program

$50 - 4.5 Hour Program      (Ticket Dismissal)

 

-  Alive at 25 - Young Driver Program

$35 - 4.5 Hour Program      (Insurance Discount/Educational)

 

 

 

2

Enter Date & Location you would like to attend:

 

 

 

 

 

All Field Must be filled in to get Registered:

 

3

Your Full Name

 

4

Your Birthday

 

5

Male / Female

 

6

What you got in trouble for

 

7

Is this your 1st time for this citation?

 

8

Case / Cause Number

 

9

Court System

 

10

Judge's Name

 

11

Phone # for Text Message Reminder

 

12

Contact Person if different that participant attending

 

 

 

 

 

Alive at 25 is limited to 20 per Class!

 

If you need the ALIVE at 25 - Young Driver Program

Additional information need as noted below:

 

 

 

14

Driver's License Number

 

15

Your Full Mailing Address, City, State, & Zip

 

 Should you have any questions, please feel free to contact us via email, text message, or by calling either of our numbers listed below.

Sincerely,

Deborah Parsons & Guy Benson

Danger Without Intentions
501(C)3 Non-Profit Educational Corporation
Drunk Driving / Victim's Impact Panel
Alcohol & Drug Awareness Programs
Alive @ 25 - Young Drivers Program
Choices and Consequences Program
Student Behavior & Truancy Awareness
Boating & Water Information Safety

www.dangerwithoutintentions.com

Toll Free:      1-866-893-2821
Phone:              512-924-9637
Fax No:             830-839-4209