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):
Emergency Contact: *
 
Emergency Contact Phone: *
- -
Relationship to Youth: *
 

Dates: (student and parent must attend BOTH classes) *
 

Gender:
     

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


Parent and student agree to participate in the Tobacco Clinic program. By submitting this form, parent and student are agreeing to complete the 2 evening classes.
     *