Healthy Relationships

This form is in TEST mode!

No payments will be collected until the Payment Feeds Feed 7 Nelnet Addon Feed is set to Production mode!

Healthy Relationships

Enrollment in the Healthy Relationships Course is $500, and includes six 90-minute workshops and up to three 60-minute one-on-one coaching sessions. Payment is due in full by the date provided by the program manager.

"*" indicates required fields

Who are you paying for?

Payment Information

Payment Contact*

First Last

Organization Name

Payment Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone*

Email for Payment Receipt*

Student Information - Max of 10 Students Per Form

Please list students below. First name, last name, and email address are required; phone number is optional.*

Payment

Price per student

Price:

Number of Students*

Please enter a number from 1 to 10.

Total

Agreements

Acceptance to Healthy Relationships Course*

I agree that I have discussed this enrollment with the Healthy Relationships Program Manager and been advised of acceptance.

Refund Policy*

I understand that no refund is available after the first workshop.

Please verify that the information entered and total is correct. When you click the “Proceed to Payment” submit button, you will be redirected to a Nelnet credit card payment page where you can securely enter your payment information. When you complete your payment, you will receive a confirmation email.