Smoke Free Home Pledge Question Title * 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: Question Title * 2. What county do you live in? Licking Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot Question Title * 3. Do you live in a single family home or a multi-family dwelling (apartment, duplex, condo, etc.)? Single Family Home Multi-unit Dwelling Question Title * 4. Are any of the members of your household under 19 years old? Yes No Next