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First Name:

Last Name:

Email Address:

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

Session 1: Find Your Why (May 9, 2024, 4:30–5:30 p.m.)Session 2: Breaking the Chain (May 16, 2024, 4:30–5:30 p.m.)Session 3: Exploring Quit Aids (May 23, 2024, 4:30–5:30 p.m.)Session 4: Engage Your Support System (May 30, 2024, 4:30–5:30 p.m.)Session 5: Stress as a Trigger (June 6, 2024, 4:30–5:30 p.m.)

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

1 - No Confidence23 - Neutral45 - Very Confident

Gender:

MaleFemaleTransgenderDo Not Identify As Male, Female, or TransgenderDecline to Answer

Age:

Race (Select All That Apply):

American Indian/Alaska Native
Asian
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White
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Ethnicity:

Hispanic or LatinoNOT Hispanic or LatinoDecline 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 (in XX format):

 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.