Healthy Androscoggin - Quit and Win Form

Quit & Win Program 2008 Enrollment

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Directions: Thank you for your interest in the program. Please complete the following information to participate in Quit & Win. This information will be used to help track and evaluate our efforts.

Section #1: Background Information

1. Name:
2. Age:
3. Gender:
4. Address:

5. Phone:
6. Email:
7. What is your preferred method of communication?

Due by:
January 16, 2008 Healthy Androscoggin

Mail:	300 Main Street Lew, ME 04240
Fax:	795-5992

Section #2: Tobacco History

8. How old were you when you began regularly using tobacco products?

9. A) What kind of tobacco products do you use? (cigarettes, pipe, spit tobacco, etc.)

9. B) How much per day?

10. What is your primary reason for wanting to quit?

11. Please specify a quit date. (Must be before 1/21/08)

Section #3: Helper Information

Please list the name and contact information for a helper that will support your efforts to quit.

12. Name:
13. Address:

14. Phone:
15. Relation:

Section #4: Program Information

16. Will you call the Maine Tobacco Helpline for support and a chance to win additional prizes?

17. How did you hear about the Quit and Win Program?

In order to be eligible for prizes you must:

Complete all information on this form and return it to Healthy Androscoggin by Jan. 16, 2008.
Remain quit between January 21, 2008 and February 25, 2008.
Record your phone calls with the Maine Tobacco Helpline to be entered into a separate drawing for $200.00.
Be present at the Quit & Win celebration in March. Details to come.