Registration for the Youth Tobacco Survey Listening Session in Lafayette, IN

1.Name:(Required.)

2.Email address

3.County of Residence:(Required.)

4.Will you be bringing any family members or other guests with you? If so, please list their names below.

Guest 1 name

Guest 2 name

Guest 3 name

Guest 4 name

Guest 5 name

5.What questions do you have about youth tobacco use (including vaping) that you would like to have answered during the event?

Registration for YTS Listening Session in Lafayette, IN