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.

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Endorsement Letter

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1. Please select: (Required.)

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

Contact Information

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2. Please provide your name: (Required.)

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3. Please provide your email address: (Required.)

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4. Please provide your county of residence: (Required.)

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

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: (Required.)

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

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

Question Title

* 1. Please select: (Required.)

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* 2. Please provide your name: (Required.)

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* 3. Please provide your email address: (Required.)

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* 4. Please provide your county of residence: (Required.)

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

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* 6. Please choose which category describes you best: (Required.)

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

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

1. Please select: (Required.)

2. Please provide your name: (Required.)

3. Please provide your email address: (Required.)

4. Please provide your county of residence: (Required.)

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

6. Please choose which category describes you best: (Required.)

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

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