SmokeFree_Philly

Smoke-free Home and Car Pledge

TAKE THE PLEDGE to make your home and car smoke-free. It's your PROMISE to PROTECT your family's health and PREVENT childhood sickness and disease.

WE ARE COMMITTED TO PROTECTING YOUR PRIVACY. Any information that you give will only be used to help create new educational and informational materials for promoting clean indoor air for children. We may contact you to complete a brief follow-up survey.

INSTRUCTIONS: Fill out this form and click the button below to take the smoke-free Home and Car Pledge. You will be directed to the smoke-free Pledge.

Name:

Email:

Phone:          Zip Code:

Race or Ethnicity:
American Indian or Alaska Native
Asian or Other Pacific Islander
Black or African American
Hispanic
White
Other

Gender:
Male
Female
Transgender
Choose Not to Answer

Age:
18-34
35-49
50-65
65+

Smoking Status:
Current Smoker
Previous Smoker
Never a Smoker


QUITTING SMOKING
Are you interested in quitting smoking? No Yes

Are you familiar with your quit smoking options? No Yes

Would you like to discuss your quit smoking options with a quit smoking counselor? No Yes

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If you are an early childhood education provider, please answer the following:

Name of your child care facility

Type of services you provide (home-based, family group, commercial, center)


Number of children who attend

Is your site smoke-free? No Yes

May we list you on this site as a smoke-free child care provider? No Yes

Remember to proudly display your Smoke-Free Home and Car Pledge!