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Alcohol Education:Alcohol Education:Safety Skills Training ProgramSafety Skills Training Program
Contact Information:
UW-Stout Counseling Center
410 Bowman Hall
Menomonie, WI 54751
715-232-2468
September 2009
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Name Tags
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Client Information Form (salmon)
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Jot Down Instructor’s Names
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Authorization to Release (gray)
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Course Fee $80 or $90
Alcohol Education:Alcohol Education:Safety Skills Training ProgramSafety Skills Training Program
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Authorization to ReleaseAuthorization to ReleaseInformationInformation
(gray form)(gray form)
1.Fill in your name & birth date2.Check - “To release to”3.Write class date in - “Dates of Service”4.Individual - fill in only if compliance is not going to court5.Office/Agency – courts (Dunn / Eau Claire)6.Address – fill in court address7.Specific Information to be released by UCC – check compliance form8.9.Sign & Date at bottom
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