BREAKTHROUGH ENTRY Program

Thank you for your interest in the BREAKTHROUGH ENTRY PROGRAM℠ - presented by LIFE REVOLUTION®!

By the way, your personal information will remain safe and secure and will only be utilized for purposes of the BREAKTHROUGH ENTRY PROGRAM℠. We don't like scammers and spammers and will therefore protect your information.

1. Select the BREAKTHROUGH ENTRY Program that applies to your son or daughter *This question is required.

If you selected "Other", what school will your son or daughter be attending this Fall?

Please enter the contact information of the student who desires to be a part of this program and the contact information of the parent who will be completing the online assessment.

Your personal information will remain safe and secure and will only be utilized for purposes of the BREAKTHROUGH ENTRY Program. We don't like scammers and spammers and will therefore protect your information!

Student First Name *This question is required.

Student Last Name *This question is required.

Student Email Address *This question is required.

Parent First Name *This question is required.

Parent Last Name *This question is required.

Parent Email Address *This question is required.

Parent Home Phone

Parent Cell Phone

4. Do you wish to have a representative of LIFE REVOLUTION contact you to explore the possibility of implementing this program for the entire incoming class of your child's new school?

BREAKTHROUGH ENTRY Program - Sign Up