Honor the Air - Native Smoke-Free Native Homes Program

Enrollment Form for Native Smoke-Free Home Education Program

Welcome and thank you for being interested in HONOR THE AIR, a program of the Tribal Youth Ambassadors for Tobacco Control Project of the California Indian Museum and Cultural Center.

We are here to help you have a home free from commercial tobacco and marijuana smoke using education materials created by the Native community for Native families in Sonoma, Lake, and Mendocino Counties.

Learn how you can protect your family and stay healthy using Native traditions by visiting our web pages at https://cimcc.org/tpp/

If you have any questions or concerns, feel free to contact us. Jayden Lim, Health Education Specialist, (707) 579-3004, jaydenalim@gmail.com, will contact you.

Yahwi!

Question Title

* 1. Age

Under 18

18-24

25-34

35-44

45-54

55-64

65+

If you are under 18, please have a parent/guardian add their contact information here and help you complete this survey.

Question Title

* 2. Contact Information

Name

Tribe/Employer

Position

Address

City/Town

State

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 3. Please share why you are interested in participating in Honor the Air Program.

Thank you for completing this survey. For more information on this Project, go to https://cimcc.org/tpp/. For any questions, please get in touch with Jayden Lim, Health Education Specialist, at jaydenalim@gmail.com; projectdirectortya4tc@gmail.com, (707) 579-3004.