Courage to Quit® Program Information

Thank you for purchasing Courage to Quit® program booklets. To assist Respiratory Health Association in tracking programs across the city please share more information with us about your Courage to Quit® Program.

First Name (Person Filling Out the Form) *

Last Name (Person Filling Out the Form) *

Email (Person Filling Out the Form) *

Information specific to your Courage to Quit Program

Program Leaders *

Start Date *

End Date *

Meeting Location *

Meeting Date *

Meeting Time *

Cost to Participants *

Is this program open to the public? *

If yes, do we have permission to publish the program information on the RHA website? *

Additional Notes (if open to the public, please provide registration information)

Upon submission of this form RHA staff will begin fulfilling your order. Thank you!

Neon CRM by Neon One

Timeout Warning

Courage to Quit® Program Information