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Adult Tobacco Quit Kit Request
Questions marked with a
*
are required
Congratulations! You're on the road to being tobacco-free. To request an adult tobacco quit kit, please fill out the information below. For questions, please call the Tobacco Prevention Program at 754-6460.
You must live in Calaveras County.
Contact Information
First Name
Last Name
Email Address
Mailing Address:
City/Town
Zip Code (Please enter your 5 digit postal code):
Age:
-- Select --
18-44
45-64
65+
Gender:
-- Select --
Male
Female
Decline to answer
Do you currently use tobacco? (cigarettes, cigars, electronic cigarettes/vapes, etc):
Yes, on a regular basis
Yes, but only once in a while
No, this quit kit is for someone else
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