* required fields
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Student First Name: *
Please enter your first name! |
Student Last Name: *
Please enter your last name! |
Parent Cell Phone: *
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Invalid Area Code Invalid phone number 2 Invalid phone number 3
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Student Cell Phone: (Optional)
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Invalid Area Code Invalid phone number 2 Invalid phone number 3
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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.)
invalid email address
Please enter your email address! |
Student Email Address: (Personal or R2.D2)
invalid email address |
Parent/Guardian Name: *
Please enter parent or guardian name!
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Dates You Will Attend: (student and parent/guardian must attend BOTH classes)
*
Please select one Tobacco Clinic date
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Gender:
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Grade: *
Please select your grade
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School Information
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Middle Schools:
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High Schools:
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Referring Administrator's Name: *
Please enter an administrator's name
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Offenses: *
Please select one or more offenses
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Reason attending Tobacco Clinic: Please choose your reason
*
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The above information will be kept in confidence.
Confidential Student Information 777777
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The Tobacco Clinic will be held online, via Microsoft Teams, on one consecutive Tuesday and Thursday per month.
To receive credit for the program, the student and an adult must attend both classes, actively participate during each class,
and the camera on your device must be on for the entire class. By submitting this form, parent/guardian and student agree to the above
requirements and to abide by the PCS Code of Student Conduct.
*
You must agree to submit and continue
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