Florida Drug and Alcohol Course Registration

Note to Parents: If you are a parent completing this form for your child, please enter your child's information, not your information! Incorrect information will prevent your child's course completion from being reported to the DHSMV.

Student's First Name:

Student's Middle Initial:

Student's Last Name:

Current Mailing Address:

City:

State:

Zip Code:

Daytime Phone Number:

/ /

E-mail Address:

License State:

Student's Gender:

Male      Female

Student's Date of Birth:

 /   / 

Last Four Digits of Student's
Social Security Number:

  Why is this needed?

How Did You Hear about Us?

Promotional Code:

(if applicable)

Please note that this is a drug and alcohol course for first time Florida drivers. This course cannot be taken to dismiss a traffic ticket.