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 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.