Tobacco Free RI Local Policy Leadership Summit RSVP 11.15.13

Question Title

* 1. About you....

Name: *

Organization:

Address: *

Unit#

City/Town: *

State:

ZIP: *

Email Address: *

Phone Number: *

Question Title

* 2. Will you be able to attend the Tobacco Free Rhode Island Leadership Summit on Friday, November 15, 2013 from 9:30 AM to noon?

Yes

If you can only attend part of the summit, please indicate your availability here.

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* 3. Please check any and all box(es) below that best describe you.

Local elected official

Local appointed official

Local health advocate

Parent

Grandparent

Educator

College student

Retailer

Youth advocate

Faith community leader

Nurse

Physician

Dentist

Substance abuse prevention specialist

Current tobacco user

Former tobacco user

Media

Coach (athletics)

Business owner

Law enforcment officer

State elected official

State appointed official

Environmentalist

Lobbyist

Retiree

PTA/PTO member

School committee member

Firefighter

Housing authority staff

Survivor of a tobacco-caused illness

Public health professional

Other (please specify)

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* 4. Tell us which local tobacco policy issues most interest you.

Preventing illegal sales to minors

Enforcement

Smoke-free outdoor public places

Reducing use access to tobacco through product placement restrictions

Hookah bars

e-cigarettes

Ending tobacco use on college campuses

Eliminating tobacco product litter

Helping smokers quit

Emerging tobacco products (smokeless, snus, orbs, etc.)

Flavored tobacco products (little cigars, smokeless)

Other (please specify)

Question Title

* 1. About you....

Question Title

* 2. Will you be able to attend the Tobacco Free Rhode Island Leadership Summit on Friday, November 15, 2013 from 9:30 AM to noon?

Question Title

* 3. Please check any and all box(es) below that best describe you.

Question Title

* 4. Tell us which local tobacco policy issues most interest you.

Question Title

* 5. If there are other topics you have or suggestions for this Summit, please send us a note in the space provided below. Thank you!!!!