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2. Name
4. Phone Number*
5. Email Address
7. Great American Smoke Out Pledge*

   1. By checking this box, I am agreeing to participate in the 2022 Great American Smoke Out (to abstain from tobacco use on November 17, 2022). I will be entered into the drawing to win a local gift bask
9. Privacy Statement:

   Plumas County Public Health Agency/TURP do not intend to save this information and the information will not be used for any other purpose than entry to the drawing.

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11. 1. Receive an email copy of this form.
12. Email address

    This field is not part of the form submission.

13. Submit

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