#iCANEndTheTrend: E-cigarette/Juul Prevention & Empowerment Program Interest Form
As we see a surge in Juul and other tobacco product use among our youth and young adults, there is a need to promote awareness and empower them to advocate for change among their peers and in their schools and communities. We are using a peer-to-peer model to help educate and create impetus for change among our youth and young adults. Please complete the following form if you are interested in a program for your school and/or group. We will reply to your request as soon as possible to confirm a date, time, and/or discuss additional details.
Email address *
School/Organization
Your answer
Contact Name
Your answer
Contact Email
Your answer
Contact Phone
Your answer
Population Served (select all that apply)
Number of sessions requested (sessions typically range from 45-60 minutes)
Training Request
Please describe the target population.
Your answer
Estimated number of participants
Your answer
Please indicate days/times that work for your group. If none, please indicate other and we will contact you to set something up .
morning
lunchtime
early afternoon
evening
other
Monday
Tuesday
Wednesday
Thursday
Friday
Other
Will we have access to any of the following?
Yes
No
Not Sure
Computer
Projector/Screen
Internet
Speaker/Sound
Please indicate any other information that will help us fulfill your request.
Your answer
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