N-O-T (Not on Tobacco) Facilitator Training

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Location: St. Albans, VT
Dates: Jan 23, 2009
Times: 10:00am – 4:00pm
Cost: There is no charge for this training. Curriculum, participant materials and lunch will be provided.

Please fill out the following information.

Participant Information:
Title	First name	Last name

Email Address

Email Address (again)

Organization or School Information:
Organization

School
(Pick 'none' if this doesn't apply.)
Other School

Other Supervisory Union

Street Address Line 1

Street Address Line 2 (Optional)

City

State	Zip

Work Phone Number

Work Fax Number

NOTE: So we can contact you in the event of cancellation, please provide your home phone number:
Home Phone Number (Please see note above)

Personal Information:
Organizational Role

Other Organizational Role

How did you hear about this training?

Other way you heard about this training if not in list above.

Please complete the following pre-assessment questions:
What are the greatest challenges you face in implementing a teen smoking cessation program in your setting?

What kind of technical assistance would help you to be successful?

When do you hope to hold your first session (fall 2008,/winter 2009/spring2009)?