Virtual Butt Stops Here Registration

The Virtual Butt Stops Here Program

The Virtual Butt Stops Here program is a 7-week tobacco cessation program made possible through a collaboration of several community health partners. Participants will learn about nicotine addiction, nicotine replacement therapies, stress management and coping techniques, share experiences and goals, and utilize a private, online social support network to aid in their tobacco cessation journey. Unlike a traditional live, in-person series, this series will be run virtually via webinar that participants can log into on a smartphone, tablet or computer.

All participants will receive program materials, log-in information and updates via email and a participant workbook and CD through the mail. You will receive an email either confirming your registration, OR your position on a waiting list for this program. Please allow up to 3 days for this email to be sent. If you do not receive an email within 5 days, or if you have questions, please contact: buttstopshereny@gmail.com

Any information collected in this questionnaire will be used solely to evaluate and improve future Virtual Butt Stops Here programs.

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* 1. Please provide your contact information.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. What is your health insurance plan?

CDPHP

MVP

Medicare

Medicaid

Empire

Blue Cross Blue Shield

Blue Shield of NENY

Other

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* 3. These are the following available sessions, please select ONLY ONE
session you would like to participate.

Wednesday, September 16 at 4pm-October 28

Fridays at 12 PM September 18-October 30

Tuesdays at 7 PM September 29-November 10 - CLOSED

Wednesdays at 7 PM September 30-November 11

Thursdays at 7 PM October 1-November 12

Wednesdays at 12 PM October 14-November 25

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* 4. How did you hear about this program?

Social media (Facebook, Instagram)

Promotional email

Website (MVP, Community Partners, St Peter's, Independent Living, Ellis Medicine)

Program flyer

My worksite health promotion program

Health care provider

Other

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* 5. Demographic Information:
Any information collected in this questionnaire will be used solely to evaluate and improve future Virtual Butt Stops Here programs.

Please select the option that corresponds with your gender:

Female

Male

Prefer not to answer

Prefer to self-identify

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* 6. Please select the option that corresponds with your age:

Under 21

21-30

31-40

41-50

51-60

61 or over

Prefer not to answer

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* 7. The Butt Stops here is committed to participation by all regardless of age or disability. In the comment box below, please let us know if you need reasonable accommodations to participate, and what those include.

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* 8. Would you like to receive a free, 3-month supply of nicotine gum, a form of nicotine replacement therapy (NRT) used to increase the chance for success in quitting? If so, the New York State Smokers Quitline is offering a free 3-month supply while supplies last. To find out if you are eligible, call 1-866-NY-QUITS (1-866-697-8487) or visit nysmokefree.com

Virtual Butt Stops Here Registration

The Virtual Butt Stops Here Program

Question Title

* 1. Please provide your contact information.

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* 2. What is your health insurance plan?

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* 3. These are the following available sessions, please select ONLY ONEsession you would like to participate.

Question Title

* 4. How did you hear about this program?

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* 5. Demographic Information:Any information collected in this questionnaire will be used solely to evaluate and improve future Virtual Butt Stops Here programs.Please select the option that corresponds with your gender:

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* 6. Please select the option that corresponds with your age:

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* 7. The Butt Stops here is committed to participation by all regardless of age or disability. In the comment box below, please let us know if you need reasonable accommodations to participate, and what those include.

Question Title

* 3. These are the following available sessions, please select ONLY ONE
session you would like to participate.

* 5. Demographic Information:
Any information collected in this questionnaire will be used solely to evaluate and improve future Virtual Butt Stops Here programs.

Please select the option that corresponds with your gender: