Youth Quit Tobacco & E-Cigarette Course Application

FREE Teen Quit Tobacco & E-Cigarette Course

Panhandle Health District offers an in-person quit tobacco and e-cigarette course throughout the five northern counties. This course is designed to address the needs and lifestyles of middle and high school students. The curriculum is designed specifically for teens and is based on the American Lung Association's INDEPTH program. It not only focuses on quitting, but also on social skills, stress management, decision making, goal setting, nutrition and physical activity. The sessions are offered once a week, for four weeks (for a total of four sessions). A certificate of completion is provided at the last class. Registration prior to the course is required.
CLASSES ARE TEMPORARY ON HOLD. COMPLETE THE FORM BELOW TO BE ADDED TO THE WAITING LIST FOR WHEN CLASSES RESUME.
Name*

First NameLast Name
Student Pronouns

He/Him/HisShe/Her/HersThey/Them/TheirsOther
Student Gender*

FemaleMaleNon-binaryOther
Name of School Student Attends
Student Age*
Primary Contact Number *
Who is the primary contact? (Name)*
Student Email*
example@example.com
Parent/Guardian Email (if under 18)
example@example.com
Register for a course

Waitlist for Hayden
What nicotine/tobacco products does student currently use (within last 30 days)?*

CigarettesCigarsE-Cigarette/Vaping Device (e.g. Elf Bar, Puff Bar, Suorin, etc.)HookahSmokeless Tobacco (e.g. chewing tobacco, snuff, dip, snus)Other
How long has student been using tobacco products or e-cigarettes?*
How did you hear about this course?*

Judge/Juvenile Court StaffPanhandle Health District Website/FacebookPrevious participantSchool Administrator (i.e. Principal, Vice Principal, Dean, etc.)School Police/Security Officer/Resource OfficerOther
If student is under 18, parent/guardian consents to student enrolling this course.*

YesNoStudent over 18
Parent/guardian name

First NameLast Name
Should be Empty: