T21 Coalition Individual Support Form: Support Protecting Youth from the Harms of Tobacco and Nicotine

Disclaimer: Your name and endorsement will not be publicly shared but may be shared with your legislators to highlight supporters from your community.

Endorsement Letter

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* 1. Select Your Level of Support

I have read the endorsement letter and would like to sign on as an individual supporter and receive coalition updates and newsletters.

I would like to receive coalition updates and newsletters to learn more, but I am not ready to sign the endorsement letter at this time.

Contact Information

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* 2. Please provide your name.

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* 3. Please provide your email address.

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* 4. Please provide your county of residence.

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* 5. Choose the category of supporter that best describes you or your area of involvement:

Parent/Caregiver

Education

Healthcare / Public Health

Youth Services / Nonprofit

Government / Policy

Business / Corporate

Faith Community

Mental Health / Counseling

College / University

Student

Tobacco Prevention / Advocacy

Law Enforcement / Juvenile Justice

Community Member

Other (please specify)

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* 6. Please choose which category describes you best:

I am age 21 or younger

I am a parent/caregiver of a youth age 21 or younger

Other (please specify)

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* 7. I would be interested in future advocacy opportunities, events, or action alerts.

Yes

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* 8. I would be willing to share my story or perspective related to youth nicotine prevention.

Yes