Freedom From Smoking® Clinic Registration Form Please print form, complete and fax to: 304-342-6096
WHO is conducting the clinic? Program recommendations support one facilitator for up to 15 participants and two facilitators for 16 or more participants.
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Lead Facilitator Name |
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Co-Facilitator (if applicable) |
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WHERE is the clinic going to be held? Provide your hospital, clinic, church, etc. name and location.
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Location (business name, etc) |
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Street |
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City, State, Zip |
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WHEN is your orientation session scheduled?
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Orientation Session Date |
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IF you’re clinic is open for the public to enroll, please provide the following information (we will post on our website).
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Contact Name |
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Phone Number for Registration |
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Thank you for registering
your upcoming clinic. Please send
this registration to Kelli Caseman by fax to 304-342-6096 or mail to: American
Lung Association of WV,