Pre-register for Your Alive at 25 Continuing Education Class
2 Part Registration (YOUR REGISTRATION WILL NOT BE COMPLETE UNTIL BOTH STEPS HAVE BEEN FINALIZED.)

1 - Complete this form.
2 - You will receive a phone call from one of our staff or a text from (910)-315-0664 to complete the registration process. This step is necessary so please be on the lookout for the communication.

Pre-registrations must be made two days before class starts. Registration closer to class start must be made by calling (910) 695-3980.

Last Name *
Your answer
First Name + (Middle Initial, optional) *
Your answer
Street Address *
Your answer
ZIP *
Your answer
City *
Your answer
State *
Your answer
County *
Your answer
Phone Number *
Your answer
Social Security Number
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Required
Race *
Required
Employment Status *
Required
Educational Level (Select Highest Level) *
Required
Email Address *
Your answer
Class Title *
Your answer
Class No. (if you have it)
Your answer
Are You a Current Student?
Emergency Contact Information (Name/Relationship/Phone) *
Your answer
Employer
Your answer
Occupation
Your answer
Driver's License No. *
Your answer
Citation No. *
Your answer
How Did You Find Out About This Class?
May we text you from (910) 315-0664?
Payment Contact Number (Name/Business, Phone and Email) *
Your answer
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