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Freedom From Smoking Facilitator Application Form
Please complete the following application for the Freedom From Smoking (FFS) Facilitator Training. The training includes participation in a 2 hour Tobacco Basics webinar AND a 1 day FFS Certification in-person workshop. Attendance at BOTH is required to receive your three-year facilitator certification.
I am applying for the following Freedom From Smoking Facilitator Training:
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*HCA Employees Only Nov Salem, VA Training: Includes Tobacco Basics live webinar Nov 4th, 11am-1pm & all day In-person training Nov 11th
Lanham, MD Training: Includes Tobacco Basics live webinar Oct 29th, 11am-1pm & all day In-person Training Nov 5th
Name
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First
Last
Organization
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Title or Position
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Address
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Street Address
Address Line 2
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State / Province / Region
Postal / Zip Code
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Philippines
Poland
Portugal
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Virgin Islands, U.S.
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Country
Email
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Phone Number
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Best way to reach me is:
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E-mail
Phone
Third Choice
Do you currently use tobacco in any form?
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Yes
No
Have you used tobacco in the past?
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Yes
No
If yes, how long ago?
Describe your previous experience in tobacco cessation education
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Describe your previous experience working with/facilitating groups
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In what medical and/or community groups do you plan on implementing the FFS program?
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Describe your plan for participant recruitment
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Will you be implementing the FFS program as part of a worksite wellness program?
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Yes
No
If yes, please describe
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Please list any of your professional organizations or affiliations
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I understand that I can be disapproved at any point in the process for volunteer service and, if disapproved, I will receive written notification
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I certify that the information that I have provided is true and correct to the best of my knowledge.
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