LIVE TOBACCO FREE Program Registration

Sign Up Today to Begin Your TOBACCO FREE life.

Thank you for your interest in the LIVE TOBACCO FREE program, as coordinated by your LIVESMART team. To get started, you can enroll with your LIVESMART Ambassador or sign up using this form. A LIVESMART Health Coach will contact you to provide more information and help you get started on your plan to quit tobacco.

If you have any questions at any time, please do not hesitate to contact a member of your LIVESMART team. We are here to support you.

For more information, please see our website at www.livesmartoni.com

Wishing you health and happiness,

Your LIVESMART Team

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* 1. MY LIVE TOBACCO FREE PLEDGE
(include any additional comments below the first two).

I, commit to participating in the LIVE TOBACCO FREE campaign. By signing this pledge, I understand:

1. Tobacco is harmful in any form and thereby commit to a healthier life for me, my family and my friends.

2. I will connect with a LIVESMART Health Coach who will assist me in developing my quit plan and support me through follow up coaching sessions (4-6 sessions throughout the year).

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* 2. Participant Information

First Name:

Last Name:

Email address:

Phone number:

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* 3. Company and Location | Spouses, please enter the location of your Spouse's workplace.

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* 4. Current Tobacco Use

Cigarettes

Cigars

Smokeless Dip/Chew

Vape/E-Cig

Please provide information on the number of years you have used tobacco. Include information on quit attempts (methods, length of time). Thank you!

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* 5. Would you be interested in completing this campaign with other participants over the phone or on a webinar?

Yes