Nicotine Free Week Registration Form February 23-29, 2020
Registration
Name of Organization/School: *
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Date of Activity or Event: *
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Number of Participants: *
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Please list all activities and events that you are planning for Nicotine Free Week. If you are looking for activities and an event to plan for Nicotine Free Week, visit the Activity Ideas section of the Nicotine Free Week page. *
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Coordinator's Name: *
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Address: *
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City: *
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State: *
Zip Code: *
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Email: *
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Phone Number: *
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Can we notify the media of your event? If yes, we will follow up with you to confirm your activity date and time two weeks prior to your event. *
Free Nicotine Free Week Supplies
Supplies are limited. Efforts will be made to fill the quantity requested.

Please enter the quantity.
Nicotine Free Week Fliers (Limit 5 per group)
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Nicotine Free Week Pencils for Elementary School Aged Youth (Limit 500 per group)
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Nicotine Free Week Pencil Sharpener Erasers for Elementary School Aged Youth (Limit 200 per group)
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Nicotine Free Week Stylus Pens for Middle and High School Aged Youth (Limit 300 per group)
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Nicotine Free Pledge Cards for Middle and High School Aged Youth (Limit 300 per group)
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Gift for Organizers:
To thank you for your hard work as a Nicotine Free Week event leader, the Department of Health will give you a free gift for participating. We'll send one per group.
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