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1 OWi 2 WEEKEND PROGRAM (96 Hour Program) In compliance with your court order, you are required to attend the OWi 2 Weekend Program provided by Des Moines Area Community College. The purpose of the program is to teach participants facts about alcohol use and abuse, and to encourage low risk choices in the use of alcohol. Your attendance at this program will also fulfill your required 96 hours of jail time. Please review all the material contained in this registration packet. Schedule: To view upcoming class dates please visit or call Check-in time: Check-out time: 5:00-5:30 p.m. both Friday's 5:00 p.m. both Sunday's Class Location: Walnut Creek Days Inn th Street West Des Moines, IA Registration: Getting To The Hotel from: North 1-35 S Merge On W, Exit Number 3, R On 8th St. R On Office Park Road. Hotel On L South 1-35 N Exit On E, Exit Number 3, R On 8th St, R On Office Park Road, Hotel On L East W, Exit Number 3, R On 8th St, R On Office Park Road, Hotel On L West E, Exit Number 3, R On 8th St, R On Office Park Road, Hotel On L Airport N On Fleur Road, L On Park Ave, R On 63rd, L On Ashworth R On 8th St, Hotel On L Side To register, please complete the registration form and the health questionnaire attached, and submit to the Court Mandated Department at DMACC by one of the following methods: Mail/In Person: DMACC/Court Mandated 1111 E. Army Post Rd., Suite 2004 Des Moines, IA Phone: Online: ce.dmacctraining.com srjones5@dmacc.edu Fax: Fee: $ Double Occupancy $1, Single Occupancy (Limited Availability) Payment method: Deadline: Cash, Credit or Debit Card, Money Order or Cashier's Check Personal checks will NOT be accepted Registrations must be received ONE WEEK prior to your first class date.
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4 DES MOINES AREA COMMUNITY COLLEGE OWi 2 WEEKEND PROGRAM REGISTRATION FORM Date of 1st Weekend: Date of 2nd Weekend: I CRN: For Office Use Only INCOMPLETE OR ILLEGIBLE INFORMATION MAY DELAY THE COMPLETION REPORT TO THE DOT. Name: Last First Social Security Number: o Male M.I. o Female Date of Birth: J j Home Address: City: State: Zip Code: Home/Cell Phone: U.S. Citizen: D Yes D No Iowa Resident: o Yes o No Are you Hispanic/Latino: o Yes o No Payment Information: Address: Ethnicity/Race: o American Indian/Alaskan Native o Black/African American o Native Hawaiian/Pacific Islander o Asian D White Payment Method: o Cash o Cashier's Check o Money Order o Debit/Credit Card Amount: o $ Double Occupany o $1, Single Occupancy Debit/Credit Card Payment Type: o Visa o Mastercard o American Express o Discover Card Number: Exp. Date: Cardholder Name: Cardholder Phone: I HEREBY AUTHORIZE DMACC TO DEBIT MY CARD FOR THE AFOREMENTIONED AMOUNT OF $ OR $1, FOR THE NON-REFUNDABLE REGISTRATION FEES. Card Holder Signature: Date: Please note: Personal Checks are not accepted, payment with cash, credit/card, cashier's check or money order is required. To guarantee a seat, payment must be included with the registration form. Once the payment is processed, the registration fee is non-refundable.,-1v_r 1lE:.' ', ),.., I A. # 00\fMUNITY COlLECf Ltfe'lt C-1Jtn11'
5 DES MOINES AREA COMMUNITY COLLEGE OWi 2 WEEKEND PROGRAM Health Questionnaire Dates of 1st Weekend: Dates of 2nd Weekend: CRN: SAFE: For Office Use Only This information is required for you protection and the protection of others. Pursuant to Section 2.7 ( 1 ), Code of Iowa, your response will remain confidential. Name: Last First M.1. Are you currently ill: o Yes o No If yes, name of illness and duration: Please check if you have any of the following: o Asthma o Hepatitis B o Hepatitis C o Diabetes o HIV/AIDS o Seizures o Heart Disease o High Blood Pressure o Tuberculosis Please list all current medications: Are you currently injured: o Yes o No If yes, date injury occurred: Explain the type and cause of injury: Have you ever been treated for a mental condition: o Yes If yes, date of treatment: o No Location of treatment: Are you now, or have you ever been suicidal: o Yes o No Please list any special accommodations needed: Medical/Disability: Dietary: Other: Emergency Contact: Phone: Release of liability I, in consideration of being allowed to participate in the Polk Count Re.sidential Program for OWi Offenders, (Print Full Name) hereby release, acquit, and forever discharge Polk County, it.s employees, officers and directors, and Des Moines Area Community College, its faculty, employees, officers and directors, from any and all liability whatsoever in connection with any injury or claim of any type or nature arising out of participation in the Program. This release includes, but is not limited to, claims for personal injury, libel, slander, defamation of character, invasion of privacy, or any other claim or cause of action, whether based upon statute or common law. Signature: Witness: Des Moines Area Community College shall not illegally discriminate on the basis of race, color, national origin, creed, religion, sex, age, or disability. Any inquiries may be directed to the EEO/AA Coordinator ( ) F lyj J.lE: '" WAf.U...VITY COt.t. CC- Life'a Callizla'
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Application for Employment We welcome you as an applicant for employment with the City of St. Michael. It is the City of St. Michael s policy to provide equal opportunity in employment. The City of St.
Application For Employment Town of Stoughton 10 Pearl Street Stoughton, MA 02072
Application For Employment Town of Stoughton 10 Pearl Street Stoughton, MA 02072 Please Print Qualified applicants are considered for all positions without regard to race, color, religion, sex, national
The Life Protector Plan
The Life Protector Plan Application for Assurance Life Protector (an Annually Renewable Life assurance) pays a lump sum in the event of death by natural or accidental cause. Policy carries a five year
Completed Application and Required records can be sent by mail or fax to:
KIDNEY AND KIDNEY/PANCREAS TRANSPLANT RECIPIENT APPLICATION LEGAL NAME: GENDER: Male Female (First) (MI) (Last) (Maiden) ADDRESS: DATE OF BIRTH: (Street) (Apt #) MARITAL STATUS: MARRIED (City) (State)
PHYSICAL THERAPY WELCOME PACKET
PHYSICAL THERAPY WELCOME PACKET Thank you for choosing Michael Johnson Physical Therapy. This welcome packet contains six forms. Please see instructions below and complete the forms accordingly. 1. New
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**ATTN: SOME PAGES NEED TO BE FILLED OUT ON BOTH SIDES** APPLICANT FLOW DATA Applicants are considered without regard to race, color, creed, national origin, religion, sex, disability, age, marital status,
Andrea Simons, DPM Davina Cross, DPM Schavey Road, Suite 2, DeWitt, MI (517) Patient History. Name: (First) (MI) (Last)
Today s : Andrea Simons, DPM Davina Cross, DPM 13105 Schavey Road, Suite 2, DeWitt, MI 48820 (517) 668-6166 Patient History of Birth: Social Security #: Name: (First) (MI) (Last) Prefers to be called Address:
CITY OF HEMET SENIOR &/or DISABLED RAMP PROGRAM 445 E. FLORIDA AVE. HEMET, CA PHONE: (951) FAX: (951)
HEAD OF HOUSEHOLD CITY OF HEMET SENIOR &/or DISABLED RAMP PROGRAM 445 E. FLORIDA AVE. HEMET, CA 92543 PHONE: (951) 765-2380 FAX: (951) 765-2359 Name Birthdate (Last) (First) (M.I.) Address Phone City SPOUSE
NOWOBILSKA MEDICAL PRACTICE PATIENT REGISTRATION FORM 4201 West 95 th Street Oak Lawn, IL 60453
NOWOBILSKA MEDICAL PRACTICE PATIENT REGISTRATION FORM 4201 West 95 th Street Oak Lawn, IL 60453 Please Print: Patient Name. First MI Last Address: City: State: Zip: Home Phone: Work Phone: Cell: Email