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Take the Smoke-Free Home Pledge!
I,
*, on
*,
* pledge to protect myself and others from the health risks of secondhand smoke by keeping my home smoke-free.
Before now, was smoking allowed in your home (by family or visitors)?
Yes
No
Do you have children under the age of 18 living in the home?
Yes
No
Would you like a
Smoke-free Home Kit
mailed to you?
Yes
No
(if
yes
, please fill out your mailing address below)
Name:
Address:
City:
State:
Zip Code:
I live in a(n)*
Single family house |
Apartment |
Condo |
Co-op |
Townhouse |
Mobile Home |
Other
If you live in an apartment, other multi-unit building, or other rental unit, does your building have a
written
smoke-free policy?
Yes
No
*Required fields
