Pledge

Student Pledge Form

Fill out the form carefully for registration
Your Name*

First NameLast Name
CELL PHONE NUMBER*
What year were you Born?*
YYYY FORMAT
Student E-mail
Phone Number*

Area CodePhone Number
SHIRT SIZE*
School*
Select your School
Have you ever Vaped Before? *Don't worry, we don't share this information with your parents*

YesNo
Do you give your consent for us to use your photo online and through our marketing/social media channels?**

YesNo
By Clicking Submit, you PLEDGE to Lead the way by:

1. Living a VAPE FREE & TOBACCO FREE life

2. Living a DRUG free life

3. Learning more about how vaping & drugs really harm people.

4. Sharing my knowledge to help create a vape-free & drug-free community.

5. Being a positive example for my peers
Should be Empty:

Student Pledge Form