#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.
Sign in to Google to save your progress. Learn more
School/Organization
Contact Name
Contact Email
Contact Phone
Population Served (select all that apply)
Number of sessions requested (sessions typically range from 45-60 minutes)
Training Request
Please describe the target population.
Estimated  number of participants
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.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of University of Kentucky.

Does this form look suspicious? Report

Google Forms