Prime for Life Registration Form First Name* Last Name* Current Mailing Address* Please provide an address where your Participant Workbook can be mailed. City* State* Zip Code* Phone Number* Email Address* Referral Source* Please indicate who SPECIFICALLY referred you to Prime for Life? (Ex. Plymouth Police Department, NH Liquor Enforcement, etc.)Available Course Dates* Tuesday, April 25th and Wednesday April 26 from 1-5pm Tuesday, May 16th and Wednesday May 17th from 1-5pm PRIME FOR LIFE IS CURRENTLY TAUGHT ON ZOOM. There is an enrollment cap for each course. Registration is on a first come, first serve, basis. You will be contacted to confirm your enrollment.Registration Fee- PayPal* Price: ***As of 12/1/22, a flat $350 registration fee will be required to take Prime for Life. No additional donation is needed. Questions? Contact Emily Shanahan at firstname.lastname@example.org.