Mother’s Day – Father’s Day 08

Quit and Win Quit Plan Training Registration Form

Presented by: Somerset Heart Health

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(One form per person entered please)
	Your Name:
	Mailing Address:
	City, Zip Code:
	Day Time Phone Number: Evening Phone Number:
	E-mail:
	Work Place (optional):
	I will be attending the training on (please place an 'x' in selected date):
	April 7th, 6:00 p.m. Bingham Area Health Center, Bingham April 14th, 5:30 p.m. Madison High School, Room 153 April 17th, 6:00 p.m. Waste Management Administration Building, Norridgewock April 30th, 5:00 p.m. Four Seasons Restaurant, Jackman May 1st, 5:30 p.m. Redington Fairview General Hospital, Conference Room 4
	A Helper (someone who will help you stay tobacco free) is also welcome to attend.
	Your Helpers' Name:
	Print off this form and return to: Somerset Heart Health P.O. Box 468 Skowhegan, Maine 04976 (fax 474-7473)