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Scott & White Smoking (Tobacco) Registration Form

* indicates required fields.
Today's Date:
First Name*:
Middle Initial/Name:
Last Name*:
Street:
City:
State:
Zip
Home Phone:*
Cell Phone:
E-mail:
Please indicate your top 2 preferred (in order) locations for attending the Scott & White's Enuff of the Puff Smoking Cessation Program*:
Indicate your preferred time for attending our tobacco cessation program.
Lunch Session Evening Session Lunch or Evening Session
How did you hear about our Freedom From Tobacco Cessation Program? (please select all that apply)
Class Flyer
Newspaper
Friend/Family Member
Poster with Handout
Healthcare Provider
S&W Website
Other
For more information about Scott & White's Tobacco Free Campus, please visit http://enuffofthepuff.sw.org. Please e-mail enuffofthepuff@swmail.sw.org or call 254-724-7878 for any questions.