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 - $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.