All families who Take the Pledge, by submitting this form, will receive a Smoke-Free Tool-kit to help make their home and vehicle smoke-free!

Gender

Age

Name

How many children under the age of 18 live in your home?

Mailing Address

Does anyone in your home currently smoke?

How many people live in your household?

PLEDGE FORM
"I pledge to protect my family from the risks of second-hand
smoke by making my home and vehicle smoke-free."