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 (Required.)

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. (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. Select Your Level of Support (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. Select Your Level of Support (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.