Tobacco Clinic Program

A collaboration with All Children’s Hospital
to educate students on the use of Tobacco, Nicotine, or Vaping devices

Tobacco Clinic Program Sign-up Form

* required fields

Student First Name: *
Student Last Name: *
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: (Personal or R2.D2)
Parent/Guardian Name: *
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. 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.