Youth Tobacco Cessation Class Registration FORM – English Required Contact Information Tobacco Cessation - Class Registration Form SMS Reminders: Yes No 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 Class Fee Paid: Tobacco Cessation - $25 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 $10.00 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.