Not-On-Tobacco Sign Up

Teens, want to quit vaping? We’re here to help! Use the form below to sign up for a future session of Not-On-Tobacco, a vaping cessation program just for teens. We’ll save your registration and let you know when the next session is scheduled. 

Student's Name *

First

Last

Student's Age

Student's Grade

Student's Phone

Student's Email *

Parent's Name *

First

Last

Parent's Phone

Parent's Email *

How long have you been using nicotine?

What are the reasons you want to quit? (Select all that apply)

• I know how it affects my health.
• My friends and family want me to quit and their opinion matters to me.
• I have noticed it affecting my activities, such as sports and school.
• I realize I am addicted and do not want it to control my life.
• Other (please add in comments)

Additional Comments

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