Prime For Life Registration Form

Participant Name(Required)

First Last

Participant Email(Required)

Enter Email Confirm Email

Participant Phone(Required)

Available Course Dates(Required)

Prime for Life is 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.

Home Mailing Address(Required)

Street Address City State ZIP Code

Prime for Life Course Workbook: Mailing Address(Required)

Enter the address to which we should mail your Prime For Life Course Workbook. Please use your current mailing address where you can recieve mail in the weeks leading up to your selected course date. It is mandatory to have this workbook for the duration of the course.

Street Address City State ZIP Code

Referral Source(Required)

Please indicate SPECIFICALLY who referred you to Prime for Life (i.e. Plymouth Police Department, NH Liquor Enforcement, etc).

Prime For Life Registration Fee(Required)

Price:

A flat $350 registration fee is required to take Prime for Life. No additional donation is needed.

Payment(Required)