Stop Smoking campaign registration form/expression of interest

LGBT HERO is teaming up with the Stop Smoking London to help build a new campaign and promote a support app called SmokeFree.

We need LGBTQ+ people who are former smokers to star in the new campaign and talk on camera about their journey to giving up smoking. It doesn’t matter how long ago you gave up smoking, we want to chat with you. Your story could help others to become smoke free.

Filming will take place in London this Summer, with location and times to be determined. We will do our best to work around your availability.

Please fill out this form, provide some basic demographic information and your email address, and we will get back to your shortly.

Question Title

1. Name:

Question Title

2. Are you a former smoker?

Yes

Question Title

3. How long have you been smoke free?

Less than 6 months

6-12 months

1-2 years

2-3 years

3-4 years

4-5 years

5-6 years

6-7 years

7-8 years

8-9 years

9-10 years

Over 10 years

Question Title

4. Which of these age bands do you fall into?

Question Title

5. What is your race or ethnic group?

Question Title

6. What is your gender?

Man (including trans man)

Woman (including trans woman)

Non-binary

Genderfluid

Agender

I use another term

Prefer not to say

Other (please specify)

Question Title

7. Are you Trans?

Trans is an umbrella term to describe people whose gender is not the same as, or does not sit comfortably with, the sex they were assigned at birth. Trans people may describe themselves using one or more of a wide variety of terms, including (but not limited to) transgender, transsexual, gender-queer (GQ), gender-fluid and non-binary.

Yes

I'm not sure

Prefer not to say

Question Title

8. What is your sexuality?

Gay

Lesbian

Bisexual

Heterosexual/straight

Asexual

Pansexual

Queer

Questioning

Other (please specify)

Question Title

9. About the campaign:

I'd like to take part in the campaign

I'd like to know more about the campaign

Stop Smoking campaign registration form/expression of interest

Question Title

* 1. Name:

Question Title

* 2. Are you a former smoker?

Question Title

* 3. How long have you been smoke free?

Question Title

* 4. Which of these age bands do you fall into?

Question Title

* 5. What is your race or ethnic group?

Question Title

* 6. What is your gender?

Question Title

Question Title

* 8. What is your sexuality?

Question Title

* 9. About the campaign:

Question Title

* 10. Please provide your email address:

1. Name:

2. Are you a former smoker?

3. How long have you been smoke free?

4. Which of these age bands do you fall into?

5. What is your race or ethnic group?

6. What is your gender?

8. What is your sexuality?

9. About the campaign:

10. Please provide your email address: