LIVE TOBACCO FREE Group Registration Form

Quitting tobacco starts now.

Thank you for your interest in the LIVE TOBACCO FREE campaign. This campaign is designed to assist you in creating your plan to quit tobacco.

We will meet as a group for a total of 4 sessions. These sessions will be held on Wednesdays at 11 am CST, beginning on April 12th. To optimize your benefit from this program, please be available to meet at this time for the majority of these sessions. If you are unable to attend a session, we will record them so you may view the missed session at your convenience.

Please fill out the form below to register. If you have any questions at any time, do not hesitate to contact the LIVESMART team at connect@livesmartoni.com. We are looking forward to working with you!

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* 1. Participant Information

First Name:

Last Name:

Email address:

Phone number:

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* 2. Company and Location | Spouses, please enter the location of your Spouse's workplace.

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* 3. Status

Employee

Spouse

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* 4. Current tobacco use:

Cigarettes

Smokeless dip/chew

E-cigs

Pipe/cigar

Other (please specify)

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* 5. Anticipated Quit Date (skip if not determined yet)

Date / Time

Date