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Manchester Smokefree Homes Registration Form

To become one of Manchester's Smoke Free homes, please tick one of the following statements and complete the registration form. (Fields marked with a * have to be filled in)

I am going to keep my home completely smoke-free

If you cannot do this now but might be able to in the future, you could register to smoke in one room of the house only and receive your award when you make your home completely smoke free)

I would like to register to smoke in one room only and work towards a smoke-free home

Name *
email address *
Address *
Post Code *
Telephone Number

1.	Are there any children between the ages of 1 and 16 in your household?
	How many?
2.	Are there any babies under 1 year or expected in your household?
3.	Number of smokers in your household?
4.	How many adult non-smokers in your household?
5.	Before registration, where was smoking allowed in the home?
6.	Before registration was smoking allowed in your car?

7.	Are you yourself a smoker?
8.	If so, who would you describe yourself?
9.	How did you hear about Manchester's Smoke Free Homes?

Additional comments

or click here to contact us.
For help with stopping smoking phone 0161 205 5998

Last Updated 15-04-10

Recent News

North Manchester Community Radio FM 106.6
Updated - 17/01/12
Listen to North Manchester Community Radio Mark Brown and Jenny Cowell talk about what support is available, across Manchester, to help people quit smoking.