Commit to Quit! Group Program Registration

First and Last Name Email Select the Session(s) You Would Like to Attend Session 1: Find Your Why (April 7, 2025, 4:00–5:00 p.m.) Session 2: Breaking the Chain (April 14, 2025, 4:00–5:00 p.m.) Session 3: Exploring Quit Aids (April 21, 2025, 4:00–5:00 p.m.) Session 4: Engage Your Support System (April 28, 2025, 4:00–5:00 p.m.) Session 5: Stress as a Trigger (May 12, 2025, 4:00–5:00 p.m.) Session 6: Staying the Course (May 19, 2025, 4:00–5:00 p.m.) Select as Many as You Like At This Time, How Confident Are You in Your Ability to Quit Using Tobacco/Vapes/Nicotine 1 - No Confidence 2 3 - Neutral 4 5 - Very Confident Gender Male Female Transgender Do Not Identify As Male, Female, or Transgender Decline to Answer Age Race American Indian/Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White Decline to Answer Select All That Apply Ethnicity Hispanic or Latino NOT Hispanic or Latino Decline to Answer County of Residence Select one... Allegany Chemung Genesee Herkimer Livingston Monroe Ontario Orleans Oswego Schuyler Seneca Steuben Wayne Wyoming Yates Other State of Residence Select one... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming How Did You Hear About the Program