FY24 Tobacco Awareness Program For Teens Enrollment

Thank you for your interest in Howard County Health Department’s Tobacco Awareness Program.

This free education program is designed for students who violate school policy on underage tobacco use. This program includes information about the risks and harms of using:

- Tobacco (cigarettes, cigars, cigarillos, smokeless tobacco)
- Electronic Cigarettes
- Dissolvable Products
- Marijuana

Please complete this online enrollment form.

Our Community Health Educator will respond within 3 business days upon receipt.

Question Title

* 1. Please complete the following information

Email of person completing form

Question Title

* 2. How did you hear about this program:
(Check all that apply.)

Howard County Health Department

Howard County Police Diversion Program

School Administrator

Other (please specify)

PERSON COMPLETING FORM

Question Title

* 3. Relationship to student:

Self

Parent/Guardian

School Administrator

Other (please specify)

FY24 Tobacco Awareness Program For Teens Enrollment

Thank you for your interest in Howard County Health Department’s Tobacco Awareness Program.

Question Title

* 1. Please complete the following information

Question Title

* 2. How did you hear about this program:(Check all that apply.)

Question Title

* 3. Relationship to student:

* 2. How did you hear about this program:
(Check all that apply.)