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If you are 14-19 years old and wish to sign up to participate in one of our smoking cessation programs, please complete the following questionnaire.

By checking this box, I am verifying that I am 14-19 years of age and that I have read and I understand the material above.

I understand that I can print a copy of this page for my records.

I am aware that my responses on this survey will be kept confidential and that my participation is entirely voluntary.

My contact information and answers will be kept in separate accounts. The only way the two are connected is with a code word of my choice.

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