100%

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:

Gender:

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