DUI Pre-Registration Forms

Choose File, Print… from your browser menu to print these forms. Each form will print on a separate page. You will need to bring the completed forms and the following items with you in-person in order to complete the registration process:

Court Order (if convicted).
Current Picture ID.
Arrest Affidavit (can be obtained at the Clerk of the Circuit/County Court). Copies must be legible.
Arrest Citation (copy must be legible).
Breath/Blood Alcohol Level reading.

Please refer to the Registration Information page you printed, to find the office location nearest you.

At the time of registration you will be scheduled for the appropriate DUI class and evaluation.

Thank You,
Director and Staff of the DUI Program

For further information, please call 407-896-1894.

DUI Program Rules

The Florida Safety Council

Dear Student:

Welcome to the Florida Safety Council DUI Program (FSC). Our program, Instructor and Evaluators are all certified by the State of Florida Department of Highway Safety and Motor Vehicles (DHSMV) to provide DUI courses for first offenders and multiple offenders who live in Seminole, Orange, Osceola or Brevard Counties. We are a reporting agency to the Courts, Probation Services and DHSMV, Drivers Licenses Bureau. We are required to report attendance or non-attendance. Our goal is to assist you completing the requirements of the DUI Program in order to retain your license or have your license reinstated by the Bureau of Driver License at the end of your revocation period. Please plan to attend since either Court of DHSMV may still require completion; DHSMV may require even if found not guilty, case dismissed; or Court may require even if license is reinstated by DHSMV prior to conviction. The following is a list of student's rules to help you with the process:

No alcohol, controlled substances or weapons will be allowed in any Florida Safety Council classroom location facility or on the grounds. Portable phones must be turned off and pagers placed on quiet mode.
No smoking in the building. Food or beverages in the classroom are not permitted. Vending machines are located in the student lounge areas for your convenience in some of our facilities. Ask your instructor for locations.
Your payment for the DUI Program course is only good for 90 days from the date of registration, according to DHSMV Administrative Rules. If you do not complete all of the DUI Program requirements within the 90 days, you will need to pay the enrollment fee again to re-enroll in the course. All fees payable to FSC are not refundable.
You MUST be on time for ALL appointments and classes. If you are late for any reason other than good cause such as documented hospitalization; documented incarceration; your own illness (documented by your physician with specific dates); documented death of an immediate family member; or a natural disaster; you will need to pay a reassignment fee and receive a new class schedule. Classes must be attended in order and will begin again with Session 1. Please refer to your class schedule or evaluation appointment paperwork for the fee.
Evaluation appointments begin on the hour and run on schedule. Each appointment lasts one hour. If you arrive late, the evaluation cannot be done and you will be required to pay a rescheduling fee. Please refer to your evaluation appointment paperwork for the fee schedule.
Classes begin on schedule, and you WILL NOT be allowed into the classroom if you arrive after the roll class has been taken. You will have to pay the amount listed on your registration form to reschedule your class.
If you come to your classes or evaluation after consuming alcohol, abusing prescription medication or another controlled substance, or if the odor of alcohol is present on your person, you will be asked to leave. If you are asked to leave, you will pay 100% of the enrollment fees to reenroll. FSC staff may perform periodic breath test. You may also be referred for urinalysis at your expense if recommended by a FSC certified Evaluator or Instructor.
If you are disruptive in class or during the evaluation appointment, you will be asked to leave. If you are asked to leave, you will pay 100% of the enrollment fees to reenroll. Disruptive behavior includes in person or over the phone.
If you need to change your evaluation appointment or class schedule, you must contact this office, in person FIVE (5) business days prior to the date assigned or first class session, to sign new paperwork. You will be allowed 2 reassignments within 90 days at no fee. If less than 5 business days prior to reschedule date, a reassignment fee will be charged.
If you wish to transfer to another In-State or Out-State DUI Program, there is a $25.00 cash transfer fee and a DHSMV form to be signed to the new Program. You must contact the new Program, and the new Program must send us updates.
Children and guests ARE NOT allowed during classes, evaluation sessions or during the registration process. Children ARE NOT to be left without adult supervision in any part of the building.
Appropriate dress is required. Appropriate behavior is expected.
If you have registered for the wrong DUI program, by withholding information on previous DUI charges or DUI program attendance and a record check by FSC or DHSMV reveals the error, you will be required to pay for the correct DUI program. The fees already paid for the incorrect program are forfeited and will not transfer.
Completion certificates are not issued until the evaluation and classes are completed.
OTHER FEES:
$15.00 Treatment Agency Transfer Fee, if you are referred and wish to change agencies.
$ 5.00 Duplicate Certificate fee, if you need to replace your DUI Completion Certificate.

We hope this information will help you with successful completion of the DUI Program.

Staff of the DUI Program


CLIENT SIGNATURE		DATE

FSC000405 Rev. 12/03

Student Conduct

The Florida Safety Council

The Department of Highway Safety & Motor Vehicles Administrative Rules allow the DUI Program to:

Dis-Enroll or Refuse to Enroll any individual who refuses to complete the folder information, answer the testing instrument, or refuses to actively participate in the evaluation appointment or the class sessions.

The Department of Highway Safety & Motor Vehicles Administrative Rules allow the DUI Program to:

Dis-Enroll or Refuse to Enroll any individual who is DISRUPTIVE or UNWILLING to COMPLY with the rules and procedures of the Program. DISRUPTIVE BEHAVIOR is defined as using abusive, threatening language or gestures; shouting or using profanity at staff or at other students; or behavior which would be unacceptable to the Court. Behavior includes in person, by telephone or by mail.
DISRUPTIVE BEHAVIOR may result in a call to 911 for escort from the premises, and possibly a No Trespass Order. A report of the Incident will be sent to the Court and/or Probation.

These guidelines were established to provide all students with a positive and safe learning environment.


STUDENT SIGNATURE		DATE

FSC000670 Rev. 12/03

CONFIDENTIAL INFORMATION

The Florida Safety Council

This paperwork and your attendance at the Florida Safety Council DUI Program is confidential and protected under State and Federal Confidentiality Laws.

This information has been disclosed to you from your records, protected by Federal confidentiality rules—Chapter 42 of the Code of Federal Regulations, Part 2 [42 CFR Part 2]. The Federal rules prohibit the DUI Program from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains (you the Student), or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information in NOT sufficient for this purpose. The Federal rules restrict any use of the alcohol or drug abuse patient.

Family members and attorneys cannot handle any aspects of this DUI Program attendance for you. This is to protect your privacy.

You will need to come in to any of the office locations in person, Monday through Friday, or Saturday mornings in Orlando, Longwood, Melbourne, or Merritt Island. Please arrive at least 2 hours before the close of business in order to complete the registration process. If you cannot physically come in, please send your question in writing to the address listed on your registration paperwork. Please plan on 3 to 5 business days for a written response to arrive.


STUDENT SIGNATURE		DATE

FSC000671 Rev. 12/03

DUI PROGRAM PRE-REGISTRATION FORM

PLEASE COMPLETE THE FOLLOWING FORM

Name: ___________________________________________________________________________________________________
Last First Middle Maiden Name

Residence Address: _______________________________________________________________________________________
Street Address Apt.#

_____________________________________________________________________
City State Zip Code County

Home Phone: (_____)______ - _______

Drivers License #: _____________________________ State: _________ Social Security #: _________- ________ - __________

Date of Birth: ____/____/____ Age: _____ Race: ____________ Sex: _____ Marital Status: ________ # of Year in School: _____

Work Phone: (_____)______-_______ Place of Employment: _______________________________________________________

REASON FOR ENROLLING IN THE DUI COUNTERATTACK PROGRAM (Price does not include MVR FEE) PLEASE CHECK APPROPRIATE LEVEL—Based upon Lifetime History in ALL states/countries—not just Florida:

DUI-LEVEL I: No prior DUI, DWI, or Reckless Driving-Alcohol/Substance ARREST or Suspension, or No prior completion of DUI Education Program or School (a First Offender - Basic) - $225.00**

DUI-LEVEL II: Prior DUI, DWI, or Reckless Driving-Alcohol/Drugs ARREST(S) or Suspension(s), or prior completion of DUI Education Program or School (a Multi-Offender) - $350.00**

DUI Special Supervision Services: Special driving privilege program for second or third or multiple DUI offender with Multiple-year revocations: 5 years or 10 years. - $295.00**

REFERRING AGENCY: Please indicate Agency Sending YOU, and WHY:

Court Ordered - indicate case number / county / state: ________________________________________________________

Drivers License Bureau requirement - (Reason: Refusal/Unlawful BAL): __________________________________________

Other - Specify Referral Source - (an attorney cannot be agency requiring attendance): ____________________________

CRIMINAL JUSTICE DATA: ALL SPACES MUST BE COMPLETED BY STUDENT

Charge: ________________________ Arrest Date: ____/____/____ BAC Level/Refusal: ________ Court Date: ____/____/____

County: __________________ Judge: _____________________________ Probation Officer: ____________________________

Total # of DUI's: ________________, and Total # of Reckless Driving-Alcohol/Substance Involvement: _______________

PREVIOUS ATTENDANCE(S) AT A DUI PROGRAM:

Yes

No, never in my lifetime

Reason Attended: ___________________________________________ Dates of Attendance: __________________________

Location (City/State): _____________________________________________________________________________________

*** Registration Fees are set by DHSMV Administrative Rules and are not Refundable ***

NOTE: IF THROUGH A RECORDS CHECK BY THE DUI PROGRAM, THE COURT, OR THE DRIVER LICENSE BUREAU, IT’S DETERMINED THAT YOU HAVE HAD A PRIOR DUI, DWI, OUI, OWI, DWAI, RECKLESS DRIVING ARREST-ALCOHOL OR DRUG RELATED; OR A PRIOR LICENSE SUSPENSION FOR ALCOHOL OR REFUSAL; OR YOU HAVE HAD A PRIOR DUI PROGRAM ATTENDANCE, IN YOUR LIFETIME, ON A FLORIDA LICENSE OR ANY OTHER STATE LICENSE RECORD, THE MONEY PAID WILL BE FORFEITED AND YOU WILL BE REQUIRED TO PAY THE FEE FOR THE APPROPRIATE CLASS.

I, the undersigned, confirm that the information provided by me above is true and correct.

SIGNED: _______________________________________________________________ DATE: _________________________

Created for completion of DHSMV Form 77004 (Rev. 1/7/97) [Part 1 of Client Data Information] FSC From 000189 (Rev 10/08)

DUI COUNTERATTACK PROGRAM

The Florida Safety Council

REGISTRATION INFORMATION

ORANGE COUNTY Florida Safety Council 427 N. Primrose Drive Orlando FL 32803 Get Map (407)896-1894 M-F: 8am to 6pm Sat: 8am to 12pm	SEMINOLE COUNTY Florida Safety Council [In Times Square Plaza] 851 E. SR 434, Suite 190 Longwood FL 32750 Get Map (407) 831-7200 M-F: 8am to 5pm Sat: 8am to 12pm	OSCEOLA COUNTY Florida Safety Council [In La Mirada Plaza] 3501 W. Vine Street 2nd Floor Suite 200 Kissimmee, FL 34741 Get Map (407) 846-2555 M-F 8am to 5pm Sat: Closed

BREVARD COUNTY Florida Safety Council 1515 Elizabeth St. Ste C Melbourne FL 32901 Get Map (321) 952-5327 M-F: 8am to 5pm Sat: 8am to 12pm	BREVARD COUNTY Florida Safety Council [In the Home Depot Plaza] 250 N. Courtenay Parkway Suite 201 Merritt Island, FL 32953 Get Map 321-631-2347 M-F: 8am to 5pm Sat: 8am to 12pm

REGISTRATION TAKES APPROXIMATELY TWO HOURS, SO PLEASE PLAN AHEAD

TUITION FEES: **

Level I – [12 Hours]	$225.00*	No Prior DUI, Reckless, Suspension or Revocation in Lifetime.
Level II – [21 Hours]	$350.00*	Prior DUI, Reckless, Suspension or Revocation in Lifetime (* Price Includes a $5 Fee for the Driver Risk Inventory - DRI Report)

Fees are payable in cash, money order, personal check, MasterCard, Visa, Discover Card or American Express. Payment plans are available, but enrollment is not completed until the full fee is paid. Driver Record (MVR) is an additional $5 Fee.

COURSE LOCATIONS:

Classes are held at all offices listed above.

EVALUATION LOCATIONS:

Evaluations are provided in all office locations. Daytime and evening evaluation appointments are available.

REASSIGNMENT FEE:

CLASSES	1^st	2^nd	3^rd or Subsequent	After 90 Days
Level I	$40.00	$ 75.00	$153.00	$225.00
Level II	$60.00	$120.00	$238.00	$350.00

EVALUATIONS	1^st	2^nd		After 90 Days
Level I	$75.00	$153.00		$225.00
Level II	$75.00	$153.00		$350.00

DOCUMENTATION REQUIRED WHEN ENROLLING IN DUI PROGRAM:

Driver License Number & Record - Florida or wherever licensed
Arrest Affidavit (Arrest Report or Crash Report) - must be a legible copy
Citation (Ticket) - must be a legible copy
BAC Level - results of Breath or Blood test, Urinalysis results
Court Disposition or Court Order, if already appeared in Court or convicted
Picture ID - such as a current Florida Identification Card, valid Passport
Driving Record Report must be less than 30 days old. **

** Tuition Fees and Reassignment Fees are approved and set by the Department of Highway Safety and Motor Vehicles. Tuition Fees are subject to change at the direction of the Department of Highway Safety & Motor Vehicles. Tuition fee is valid for only 90 days from date or enrollment. After 90 days the full fee is paid again and both evaluation and classes are started again (classes always start over with class session 1.) If the student arrives at class or evaluation under the influence of alcohol or other drugs or is disruptive or threatening, the full fee will be paid again. The Driving Record can be ordered through our office. Please call for Driving Record prices as each state varies in cost: Florida - $5.00