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Freedom from Smoking Registration Form
Which session of "Freedom from Smoking" are you applying for?
Choose just one session
Will you accept text messages on this phone?
This program is 12 sessions. Do you agree to attend all 12 sessions?
Which of the following best describes your health insurance status?
A deposit of $10 is required for this class. This amount will be refunded to you once you complete all sessions. If you need a scholarship, please contact Rachelle at 402-421-2924.
Credit Card Information
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