Smoke Free Home Pledge

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* 1. TAKE THE PLEDGE to make your home smoke-free. It's your PROMISE to PROTECT your family's health and PREVENT childhood sickness and disease.

Name:

ZIP:

Email Address:

Phone Number:

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* 2. What county do you live in?

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* 3. Do you live in a single family home or a multi-family dwelling (apartment, duplex, condo, etc.)?

Single Family Home

Multi-unit Dwelling

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* 4. Are any of the members of your household under 19 years old?

Yes

No