REGISTRATION FORM

I WANT TO SIGN-UP FOR 12 WEEKS TO FREEDOM!

STARTING October 1, 2021

Please fill in the following information in BLOCK CAPITAL LETTERS.

Print it out and POST to Unit B, Enterprise Park, Innishmore, Ballincollig, Cork

NAME: ________________________________________________________________ 

ADDRESS: _____________________________________________________________

CITY, COUNTY: ________________________________________________________

PHONE: __________________________________   BIRTHDATE _________________

I request the following:

[_]  To apply for the next available 12 Weeks to Freedom course

[_]  More information about TWTF of Cork

[_]  Free consultation about addictions and help to break free of them

[_]  Information about the New Hope Men's Residential Centre in Tallaght, Dublin

POST TO:

TWELVE WEEKS TO FREEDOM

   Unit B, Enterprise Park, Innishmore, Ballincollig, Cork

Meeting Fridays, 7-9pm, in the same address

Or Contact Tony Mahony via:    087-955-6224     biblebc@gmail.com     www.biblebc.com/twtf