Breathe Virtual Training Registration

Please complete the following information below to be registered for the "Breathe: Healthy Steps to Living Tobacco-Free" Virtual Training! This training will be held Friday, March 12 from 11:30 AM- 1:00 PM EST.

Question Title

* 1. Contact Information:

First & Last Name:

Email Address:

Organization you work for:

Mailing Address you want Breathe Materials sent to:

City/Town

State/Province

ZIP/Postal Code

Question Title

* 2. County where your organization is located:

Question Title

* 3. Please select the title/role that best describes your position(s) within your organization (check all that apply):

Health Educator

Social Worker

Health Care Worker

Classroom Teacher / Aid

Home Visitor

Agency / Center Director

Other Leadership Position

Other (please specify)

Question Title

* 4. Have you had any previous tobacco training/education?

Thank you for your registration to attend the virtual "Breathe: Healthy Steps to Living Tobacco-Free" training!
More information about the training, including the Zoom link to join, will be emailed to you from JustBreatheIndiana@gmail.com closer to the training date.
If you have any questions please email JustBreatheIndiana@gmail.com.