* required fields
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Student First Name: *
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Student Last Name: *
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Grade: *
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Parent/Guardian Name: *
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Parent Cell Phone: *
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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.)
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Student Email Address: (Personal or R2.D2) *
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Student Cell Phone: (Optional)
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Dates You Will Attend: (student and parent/guardian must attend BOTH classes)
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Gender:
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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: *
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Offenses: *
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Reason attending Tobacco Clinic:
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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.
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