Virtual Nicotine Cessation Program

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

PARTICIPANT REGISTRATION FORM

The Nicotine Cessation Program is free and that takes place over the course of 7 weeks (weekly 1 hour sessions). Participants learn behavioral modifications, stress management, and other techniques to help them quit using products containing nicotine, including cigarettes, cigars, dip, and electronic smoking devices (ESD).

Email *

Name: *

Date of Birth: *

YYYY

Phone Number: *

Race/Ethnicity (optional) check all that apply:

Black or African American

White or Caucasian

Asian

American Indian or Alaskan Native

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

What is your primary language? *

English

Spanish

Tagalog

Vietnamese

Other:

Gender

Are you pregnant? *

Yes

N/A

Have you quit before? If yes, tell us how many times and what methods you tried.

Please select desired class schedule: *

Tuesdays: March 12, 2024 – April 23, 2024 (5:30 – 6:30 p.m.)

Tuesdays: May 14, 2024 - June 25, 2024 (5:30 - 6:30 p.m)

Would like more info prior to registration

Please choose meeting preference.

Please note: We will do our best to accommodate this.

Virtual

In-person

Hybrid

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of State of Maryland. Report Abuse

Forms