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Your Life and Community
Make your Home Smoke Free
We are asking people to help make Rushmoor smoke free, by taking our Smokefree Homes pledge. By signing up you are agreeing to protect children and other people, by not smoking in your house or car. More information about this scheme is on
http://www.rushmoor.gov.uk/index.cfm?articleid=8345
I support the Smoke Free Homes campaign and I pledge to make my home smoke free
Name:
*
Address:
*
*
Postcode:
*
Email:
Telephone Number:
*
Number of smokers in your home:
Before making this pledge, where was smoking allowed?
Nowhere
Only in one room
In most rooms
Everywhere
Where did you hear about the Rushmoor Smoke Free Homes campaign?
I am ready to receive a call from the Hampshire Fire and Rescue Service to carry out a free home safety check
Yes
No
I am ready to receive a call from the NHS Quit4Life Service to support me to quit smoking
Yes
No
I am ready to receive a call from Rushmoor Healthy Living to support me to a healthier lifestyle
Yes
No
Please Note: The personal details you provide will only be used for the purposes stated.
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