Good Success Home Study Registration

1. Please Provide The Information Below

100% of survey complete.

The information you're about to give us will help insure that you are properly credited for the Home Study Course you're going to complete. It will also guarantee notification of the correct PTI Case Manager once you complete the Home Study Course.

Thanks for taking the time to give us accurate information.

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* 1. Please let us know how you can be contacted:

Name:

Email Address:

Best Phone #

PTI Case Mgr's Name

PTI in which county?

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* 2. What was the charge that resulted in you participating in PTI?

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* 3. If there is someone else who might be purchasing the Home Study Course for you, please give us that person's name.

Sometimes a parent or friend will purchase the Home Study Course, and that person's name and information ends up in the reports to your PTI Case Manager -- when it needs to be YOUR name and information. So please let us know if someone else is going to purchase the Home Study course for you.

If this does not apply to you, just put "NA" in the answer section.

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* 1. Please let us know how you can be contacted:

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* 2. What was the charge that resulted in you participating in PTI?

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* 4. This Section To Be Completed By Good Success Staff: