PNC: Empower to Quit Registration

Providence Nicotine Cessation

Empower to Quit: Understanding Your Nicotine-Free Journey
Do you currently use a nicotine product?*

YesNo
As this class focuses on the steps to living a nicotine-free life, participation in our series is reserved for individuals currently using nicotine products (smoking, vaping, or chewing) and who have a desire to quit. We appreciate your interest and are unable to complete your registration at this time. Please feel free to email us with questions.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How did you hear about us?*
Are you a Providence employee?*

YesNo
What is your employee ID number?*
Please select your preferred session dates. Offered on Wednesdays, 4-6:00 p.m. PT.*

Feb. 4Apr. 15Jun. 24Sep. 16Dec. 16
Optional Demographic Information

Would you consider helping us continue to offer, improve, and enhance our free community classes and programs? This demographic information will help us improve our ability to serve our participants, enhance funding, and perform research around healthy lifestyle behaviors and our community-centered programming. All research data will be de-identified. We do not sell or give your information to third parties.
Would you mind answering our demographic questions?*

Happy to answer!No thanks.
Age
What race(s) do you consider yourself to be?

Alaska NativeAmerican IndianAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderWhite/CaucasianSome other racePrefer not to sayUnknown
Do you consider yourself to be Hispanic or Latino?
How do you identify?

ManNon-binaryWomanPrefer to self-describe
PARTICIPANT WAIVER

Please read the information below and then check the box indicating your understanding.
By checking the box below, you understand the following: I understand my name will be added to the Basecamp Prevention + Wellness contact list to receive information related to health and wellness. We do not share our database with outside groups.
Participant Waiver Acknowledgment*

I understand
If you have questions or comments regarding this registration or the upcoming Nicotine Cessation, please send us an email.
Should be Empty:

Providence Nicotine Cessation

PARTICIPANT WAIVER