SmokeCheck workshop registration form 2012
Indigenous Smoking Cessation Training
Please fill out the following:
* required fields
Title:
Please select an option
Miss
Ms
Mrs
Mr
Dr
other
First Name: *
Surname: *
Position:
Organisation:
Type of Organisation: *
Local Health District
Aboriginal Community Controlled Health Service
Non-Government Organisation
Other
Workshop/Date: *
Please select an option
15 May - Newcastle
I am attending the workshop: *
Please select an option
for the first time
as a refresher
Mobile/Phone: *
Email: *
Are you of Aboriginal or Torres Strait Islander descent?
Yes
No
Both
Postal address
Street Address: *
Suburb/Town: *
State: *
Postcode: *
Smoking Status
SmokeCheck encourages the participation of all health practitioners, regardless of their personal smoking status.
To help us in our program support activities, can you please indicate:
I am a smoker/occasional smoker
I am not a smoker
I prefer not to say
How did you hear about the SmokeCheck Workshop?
manager/colleague
SmokeCheck website
SmokeCheck newsletter
Learning & Development website
word of mouth
previously attended a workshop
other website / mailing lists
local media
other
