Alcohol And Drug Early Intervention Services In Dayton


Registration Forms


Printed Registration Forms


The following forms may be printed, completed and mailed along with your program fee to the address below.
You may download the forms in either Microsoft Word or Adobe PDF.
PDF forms require Adobe Reader, a free download.
These forms must be received in our office two weeks prior to your attendance



You may also register online by completing the form below.
To view our security features scroll down to the bottom of the page.

* Designates required field

*Your Full Name
*Phone
Turing Number
*Verification Code

     * required fields




All Fields below are optional
Referred by
Street Address
City
State
Zip Code
Business/Work Phone
Date of Birth
Gender Male: Female:
Ethnicity/Race
Marital Status
Are you a smoker? Yes: No:
Place of Employment
Occupation
Employment Hours Full-time: Part-time:
Are you currently a student?
If so where?
Emergency Contact
Relationship to you
Street Address
City
State
Zip Code
Telephone Number
YOU MUST BRING PRESCRIPTION MEDICATIONS IN BOTTLES CLEARLY INDICATING THAT THEY HAVE BEEN PRESCRIBED TO YOU. BRING ONLY THE AMOUNT NEEDED TO GET THROUGH THE WEEKEND. NO OVER-THE-COUNTER ITEMS MAY BE BROUGHT TO THE PROGRAM INCLUDING TYLENOL, ADVIL, ASPIRIN, VITAMINS, SUPPLEMENTS, OINTMENTS, CREAMS, ETC.
Please describe below any medical condition(s) you have and the medication(s) you are taking.
Please list all known allergies and/or food reactions.
Are you currently pregnant (females only)? If yes, how many months? List difficulties/problems, if any.
Do you have any special dietary requirements (e.g., gluten free, vegetarian, etc.) we should know about?
Please list any special (non-dietary) requirements you have.

     * required fields

Printed Registration Forms


The following forms may be printed, completed and mailed along with your program fee to the address below.
You may download the forms in either Microsoft Word or Adobe PDF.
PDF forms require Adobe Reader, a free download.
These forms must be received in our office two weeks prior to your attendance



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