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Intake form needs to be completed and paid at least 1-week prior to proposed trial start date

I am the

First Name

Last Name

Phone *

Email *

Trial Type of PEP Interested In

Trial Time Interested In

School Type

Input All Grade Levels To Service

School

Address

City

State/Province

Zip/Postal Code

Trial Overall Anticipated Number of Participants

PEP Anticipated Trial Date

PEP Trial Class Anticipated Start Time (1 hour maximum time)

PEP Trial Class Anticipated Secondary Start Time (1 hour maximum time)

*Upon contract signing this amount will be credited back to your account. *

School Sponsored- PEP Trial Class

$250

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