Second Chance Contract Request

Second Chance Contract Information

If you are ready to purchase Second Chance, please complete this form. A Second Chance team member will draw up a contract and invoice based on the information you submit and will return it to you in ~3-5 business days. Once the contract is signed and returned to RMC Health, all administrators will be approved and can begin using Second Chance.
School, District, or Organization Name (Licensee)*
Licensee Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo - send it to a different address.
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Licensee Point of Contact*

First NameLast Name
Contact Job Title*
Contact Phone Number*
Format: (000) 000-0000.
Contact E-mail*
example@example.com
Invoicing Email*
example@example.com
Select the number of schools/sites to subscribe.*
prevnext( X )
Second Chance One Year Subscription
Gives access to one site with one Second Chance administrator for 12 months. Multi-site pricing discount applied based on quantity selected.

$1,500.00 Quantity

Virtual Administrator Training
One (1) 60-minute personalized virtual training for up to six Second Chance administrators to learn about program implementation and revise school/district policies around tobacco use violations.

$825.00 Quantity

Total

$0.00
Please list all site names, along with the Second Chance Administrator name and email address for each site. *
Teacher/Administrator ReferralLPHA ReferralPrevious Second Chance UserConferenceRMC Health WebsiteWeb SearchSocial MediaOther - Please specify
Email
example@example.com
Date

MonthDayYear
Date
Should be Empty:

Second Chance Contract Information