Manchester Smoke Free 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

Are there any children between the ages of 1 and 16 in your household? Yes No how many? 0 1 2 3 4 5 6 7 8 or more

Are there any babies under 1 year or expected in your household? Yes No

Number of smokers in your household? 0 1 2 3 4 5 6 7 8 How many adult non-smokers in your household? 0 1 2 3 4 5 6 7 8

Before registration, where was smoking allowed in the home? Nowhere 1 room only Most rooms Everywhere

Before registration was smoking allowed in your car? Yes No Sometimes I don't have a car

Are you yourself a smoker? Yes No If so, ho would you describe yourself? I do not want to quit I would like to quit I want to quit within 6 months I want to quit within the next month I am already trying to quit

How did you hear about Manchester's Smoke Free Homes? Word of mouth Direct mail Show/event Health visitor Midwives SureStart Advertisement Internet At work Leaflet Other

Additional comments

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