Complete this form to register for Quit & Win 2019. We look forward to seeing you starting Wednesday, January 9th from 5:30 to 7:00pm at the Dempsey Center (29 Lowell St, 5th Floor, Lewiston). We will meet every Wednesday for 5 consecutive Wednesdays in a row. Eligibility Requirements for the cash and prizes: Must attend four out of the five classes. Must live, work or go to school in Androscoggin County and be 18 years of age.

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your street address?

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* 4. What is your telephone number? 

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