Tobacco Clinic Program

Tobacco Clinic Program Sign-up Form


* required fields

First Name: *
 
Last Name: *
 
Address: *
 
City: *
 
State: *
 
Zip Code: *  
Home Phone:
- -
Work Phone:
- -
Cell Phone: *
- -
Email Address
(A confirmation email will be sent to you shortly after you register):

Parent/Guardian: *

 
Parent Address (if different):
Emergency Contact: *

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

Tobacco Clinic Location and Month: *
Clearwater High School:


Dixie Hollins High School:


Gender:
   

Grade: *
 
School Information
Middle Schools:

High Schools:


Administrator's Name: *
 

Offenses: *  





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


I agree to participate in the Tobacco Clinic program. By submitting this form, you are agreeing to complete the 2 evening classes. Confidential Student Information 777777
     *