Freedom From Smoking Sign-Up Questionnaire

Quitting tobacco made easier with American Lung Association’s Freedom From Smoking, facilitated by our tobacco coordinator here at JCHD. All responses are kept confidential.

1. First and Last Name

2. What’s your gender identity?

Please enter an 'other' value for this selection.

3. What’s your age?

4. Phone number?

5. When would you like to be contacted?

6. Email address (Emails will be sent out along with calls)