Anger Management Program Enrollment Please complete the participant intake form below before continuing to program enrollment. First Name *Last Name *Date of Birth *Email Address *Phone *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *County of Case *Charge / Offence *Case NumberAre you currently under probation/bond/parole?Select the correct optionProbationBondParoleNot ApplicableProbation Officer Name *Probation Officer Email Address *Probation Officer Phone Number *Upload Government Photo IDChoose FileNo file chosenDelete uploaded fileUpload Court OrderChoose FileNo file chosenDelete uploaded fileProgram Participation Agreement *By enrolling in this program and selecting this checkbox, I agree to the following conditions: • You will complete all required lessons and program activities.• Program participation must remain respectful and non-violent.• Threatening or abusive behavior may result in removal from the program.• Participants must not attend sessions or complete activities under the influence of drugs or alcohol.• Program completion requires fulfilling all participation requirements. Information about enrollment, participation, progress, and completion may be shared with courts, probation officers, attorneys, or referring agencies when required. This program is an educational intervention program and does not provide counseling services.Payment & Refund Policy *By enrolling in this program and selecting this checkbox, I acknowledge that: • Program fees are non-refundable once access to the program has been granted.• Access to digital course materials may be provided immediately after enrollment.• Chargebacks or payment disputes after accessing course materials may result in removal from the program.• Certificates of completion are issued only after all program requirements and payments are completed.Identity Verification *I confirm that the identification document uploaded belongs to me.Electronic Signature NoticeBy typing your name and submitting this form, you agree that your electronic signature is legally binding and equivalent to a handwritten signature. This submission records your IP address, timestamp, and submitted information for verification purposes.Full Legal Name (Electronic Signature) *Typing your full legal name below serves as your electronic signature and confirms that you agree to the program participation agreement and payment policies.Electronic Signature Confirmation * I confirm that typing my name above constitutes my electronic signature. Program Agreement * I certify that the information provided is accurate and I agree to the program participation policies, payment terms, and course requirements. Submit
