We Can Quit - Registration Form

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Quit that smoking habit for good. Save money and feel great!

We Can Quit is a free, friendly and supportive 12 week programme for people who smoke and want support to quit smoking.

This programme is for individuals over 18 years of age, who live in the area and want support to quit smoking.

We Can Quit offers:

Weekly group support,
Weekly one to one support and
Free stop smoking medication

Registrations are now open for courses taking place across Fingal. Please register your interest for the area most convenient to where you live.

Priority will be given to those living in the local community where the course is being delivered. Courses are due to start April 2023.

Courses will be delivered both in person and online.

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Todays Date

Date

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Full Name* This field is required.

First Name

Last Name

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Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Phone Number* This field is required.

Area Code

Phone Number

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Email

example@example.com

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Date of BirthPlease fill in your Date of Birth

Date

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Gender

Male

Female

Not specified

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Do you smoke?

YESNO

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Have you tried to quit smoking before?

YESNO

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Would you like support to quit smoking?

YESNO

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Aster FRC, Balbriggan, Monday, 17th April, 6.00pm to 7.30pm

Blakestown CRC, Dublin 15, Tuesday 18th April, 6.00pm to 7.30pm