SmokeCheck - Working towards smoke free
Aboriginal communities in NSW

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SmokeCheck Registration Form

Indigenous Smoking Cessation Training

Please fill out the following:

This form was not completed correctly. Please review the items in red.

* required fields

Title:

First Name: *

Surname: *

Position:

Organisation:

Type of Organisation: *

Area Health Service

Aboriginal Community Controlled Health Service

Non-Government Organisation

Other

Workshop/Date: *

Mobile/Phone: *

Email: *

Are you of Aboriginal or Torres Strait Islander descent?

Yes

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

Authorised by: Head of SmokeCheck. Last updated: 19-Jul-2010

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SmokeCheck - Working towards smoke freeAboriginal communities in NSW

SmokeCheck Registration Form

SmokeCheck - Working towards smoke free
Aboriginal communities in NSW