Registration Form for N.E.W. LIFE Online Program

Print and send completed form to:

N.E.W. LIFE
144 Sherry Street 
East Islip, New York  11730
Make check or money order  payable to:  Diane Preves, M.S., R.D.

Name  ____________________________________________________________________


Street Address  _____________________________________________________________

Apt. #  _______________                 or                   P.O. Box  ____________   


City  _________________________________   State   ____________   Zip  __________



Home phone (_____)_______-___________ 

Cell phone    (_____)_______-___________ 

Work phone (_____)_______-___________ 


E-mail  _______________________________________________________

Pre-payment required


____  I have enclosed a check or money order for $200

As soon as your payment is processed you will receive a Participant Data Form and a Physician Release Form by e-mail.  Please check here if you would prefer to receive them by mail.  ____

Please indicate here the code for the N.E.W. LIFE program you are selecting  ___ ___ ___ ___