Please fill out the following to register for the WakeUp! Program Wake UP! Registration Today's Date* Date Format: MM slash DD slash YYYY Referred by*ProbationSchoolOtherStudent Name* First Last Student Phone*Student age*Referral ReasonMarijuanaAlcoholVapingOtherProbation Officer name (if applicable)School attending*WakeUP Start Date*Wake Up Programs start the first Saturday of each monthOctober 3, 2020November 7, 2020December 5, 2020January 9. 2021February 6, 2021March 6, 2021April 10, 2021Parent/Guardian Name First Last Parent/guardian email Parent/Guardian phoneAddress* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Yes, please send me information about Arizona Youth PartnershipYESNOPay for Wakeup*If your student was referred by Amphitheather School District, you do not need to pay. If you are referred by any other source, you can pay online or bring cash or cashier's check/money order to the first session10 hours community service5 hours community serviceNo community serviceReferred by AmphiI have received a waiver of feesTotal $0.00 EmailThis field is for validation purposes and should be left unchanged.