Project Prevent OR PPYC

Congratulations on making the choice to join a group of youth dedicated to being the last generation of tobacco and nicotine users! Please complete the form below in its entirety.

What is your first name?

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* 1. What is your first name?

What is your last name?

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* 2. What is your last name?

What is your gender?

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* 3. What is your gender?

How old are you?

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* 4. How old are you?

Are you a member of a local youth tobacco coalition? If so, please list the name of the coalition in which you currently participate. NOTE: Membership in a local coalition is NOT required for membership in the Project Prevent Youth Coalition. 

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* 5. Are you a member of a local youth tobacco coalition? If so, please list the name of the coalition in which you currently participate. NOTE: Membership in a local coalition is NOT required for membership in the Project Prevent Youth Coalition. 

What is your email address? (Gmail, Hotmail, iCloud, Outlook, etc.) Please do not use a school email address. 

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* 6. What is your email address? (Gmail, Hotmail, iCloud, Outlook, etc.) Please do not use a school email address. 

Please re-enter your email address. 

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* 7. Please re-enter your email address. 

In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 8. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

PPYC uses Remind101 to stay in touch with its members. Please share your phone number so that you can be added to our list.

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* 9. PPYC uses Remind101 to stay in touch with its members. Please share your phone number so that you can be added to our list.

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