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
City
State / Province
Postal / Zip Code
Should we send your invoice to the address listed above?
Yes
No - send it to a different address.
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Licensee Point of Contact
*
First Name
Last Name
Contact Job Title
*
Contact Phone Number
*
Contact E-mail
*
example@example.com
Invoicing Email
*
example@example.com
Select the number of schools/sites to subscribe.
*
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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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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
1
2
3
4
5
6
7
8
9
10
Please list all site names, along with the Second Chance Administrator name and email address for each site.
*
How did you hear about Second Chance?
Teacher/Administrator Referral
LPHA Referral
Previous Second Chance User
Conference
RMC Health Website
Web Search
Social Media
Other - Please specify
Email
example@example.com
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: