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Youth 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.