Please Note: Registration closes 24 hours prior to each session.

place field "FirstName" below

First Name

place field "LastName" below

Last Name

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Email Address

place field "Session" below

Select the Session(s) You Would Like to Attend (Select as Many as You Like)

Session 1: Find Your Why (November 7, 2024, 5:00–6:00 p.m.) Session 2: Breaking the Chain (November 14, 2024, 5:00–6:00 p.m.) Session 3: Exploring Quit Aids (November 21, 2024, 5:00–6:00 p.m.) Session 4: Engage Your Support System (December 5, 2024, 5:00–6:00 p.m.) Session 5: Stress as a Trigger (December 12, 2024, 5:00–6:00 p.m.) Session 6: Staying the Course (December 19, 2024, 5:00–6:00 p.m.)

place field "Confidence" below

At this time, how confident are you in your ability to quit using tobacco/vapes/nicotine?

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Gender

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Age

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Race (Select All That Apply)

American Indian/Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White Decline to Answer

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Ethnicity

Hispanic or Latino NOT Hispanic or Latino Decline to Answer

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County of Residence

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State of Residence (in XX format)

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How did you hear about the program

I understand that participation in the Commit to Quit! program is confidential and agree to contribute to the supportive, non-judgmental environment of the program.

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Center for Community Health & Prevention

Patient Care

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