Register

Online DIP Registration Form

Only new first time students registering to begin the online program should complete this form and then select Submit at the bottom of the page.

Returning users who are continuing with the program please select
Back to Participant Login.

* = Required Fields

First and Last Name*:
Street Address*:
City*:
State*:
Zip*:
Date of Birth*:	(mm/dd/yyyy)
Drivers License #*:	(do not include dashes) ex) A999999999999 or MD99999999999
Confirm Drivers License #*:	(do not include dashes) ex) A999999999999 or MD99999999999
Primary Phone*:	[ (999) 999-9999 ]
Secondary Phone:	[ (999) 999-9999 ]
Email*:
I have read the Policy Information*