Andrea's Project Victim Impact Panel Sign-Up
Participant Registration Form
Name
First Name
Last Name
Age
E-mail
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who referred you to the VIP program?
Probation Office
Parolee Office
Judge
Other
When was the date of your arrest?
-
Month
-
Day
Year
Date
Select which class you would like to attend
Please Select
Tuesday 9/9/25, 6 PM-8 PM
Tuesday 10/14/25, 6 PM-8 PM
Tuesday 11/11/25, 6 PM-8 PM
Tuesday 12/9/25, 6 PM-8 PM
Payment
Payment Options
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( X )
Registration- Pay now
Pay by credit, debit, apple pay, or google pay
$
50.00
Registration- Pay day of class
Click this option if you will be bringing a money order to the class and not pay by debit or credit
$
Free
Request scholarship to attend at no charge
If you would like to request that your fee be waived due to economic hardship- please select this option. Your Probation Officer will be contacted to verify.
$
Free
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
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