Adult Tobacco Cessation Class Registration

FORM – English

    Required Contact Information




    Tobacco Cessation - Class Registration Form



     








     

    Gender: Male   Female
    Race:White   American Indian   Asian   Latino   Black   Pacific Islander   Alaskan Native   Other
    Ethnicity:Puerto Rican   Mexican   Cuban   Other   Not of Hispanic Origin


    Tobacco Cessation

    The class fee must be paid prior to the class you are scheduled to attend. If you fail to attend the scheduled class, you will be charged to reschedule for the next class. You have only 2 opportunities to complete the class without exception. Classes can be paid for at either of the following locations:

    Bear River Health Department |
    Division of Health Promotion |
    655 E. 1300 N | Logan

    Bear Bear River Health Department |
    800 W. 992 S. |
    Brigham City

    Click the SEND button only once. It will take just a moment to process your information. You will receive a confirmation email if your submission was successful.