Tobacco Clinic Program

A collaboration with All Children’s Hospital
to educate students on the use of nicotine products

Tobacco Clinic Program Sign-up Form

* required fields

Student First Name: *
Student Last Name: *
Address: *
City: *
State: *
Zip Code: *
Home Phone:
- -
Parent Cell Phone: *
- -
Student Cell Phone: (Optional)
- -

Parent Email Address: *
(A confirmation email will be sent to you 1-2 school days after you register.
The message may go to your spam/junk folder, so please check that as well.)

Student Email Address: (Optional)
Parent/Guardian: *
Parent Address (if different):
Dates You Will Attend: (student and parent/guardian must attend BOTH classes) *


Grade: *
School Information
Middle Schools:

High Schools:

Referring Administrator's Name: *

Offenses: *  

Reason attending Tobacco Clinic:  
The above information will be kept in confidence.
Confidential Student Information 777777

The Tobacco Clinic will be held online, via Microsoft Teams, on one consecutive Tuesday and Thursday per month. In order to receive credit for the program, the parent/guardian and student must attend both classes. By submitting this form, parent/guardian and student are agreeing to complete the 2 evening classes and to abide by the PCS Code of Student Conduct.