Registration

All information on this questionnaire will be kept confidential. Please fill out this web form.

Name
Address

Studies show some communities and demographic groups have higher rates of tobacco use than others. The American Lung Association is interested in knowing who we are serving with Freedom From Smoking. All questions in this section are optional.

Which of these best describes your race or ethnic group? (Check all that apply/add multiple check box option for user)
What’s your gender identity?
Do you think of yourself as (check all that apply):

Your History of Tobacco Use

5. Do you use tobacco in any form other than cigarettes? If YES, please check boxes below:
6. In which settings do you spend time with others who smoke? (Check all that apply.)
7. How supportive do you think each of these people will be of your goal to quit smoking?
Husband/wife/partner
Children
Friends
Co-workers
8. How did you learn about our Freedom From Smoking Class?
CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
3 + 11 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.