Not on Tobacco Facilitator Training

Not On Tobacco Facilitator Training

Registration Form

Registration is required. A separate form must be used for each person and session.

REGISTRATION DEADLINE IS ONE WEEK PRIOR TO TRAINING DATE.

Trainings will take place as scheduled only if a minimum of 10 people per session are registered.

A Confirmation, including directions, will be emailed prior to the training.

Please call 262.703.4200 if you do not receive a confirmation or if you have any questions.

NAME: / CREDENTIALS:
ORGANIZATION: / TITLE:
MAILING ADDRESS:
CITY: / STATE: / ZIP:
COUNTY: / DAYTIME PHONE:
EMAIL: / BUSINESS FAX:
HOME PHONE (in case of inclement weather):
TRAINING / PROGRAM
Not On Tobacco (N-O-T):
Wisconsin resident: $50.00 Registration Fee
Non-Wisconsin resident: $200.00 Registration Fee
TRAINING DATE: ______
TRAINING LOCATION: ______
PAYMENT METHOD:
Bill Me: ______
______
(Include address if different than above)
Check or Money Order Enclosed: $ ______
(Make checks payable to American Lung Association) / Charge to Credit Card: $ ______
Visa MasterCard
Account # ______
Exp. Date: ______
Signature: ______
Name (print): ______

FAXthis form to 262.781.5180 to ensure timely receipt. Mail checks with copy of registration to:

American Lung Association in Wisconsin, Attn: N-O-T

13100 W. Lisbon Road, Suite 700, Brookfield, WI. 53005

FACILITATOR TRAINING

The American Lung Association of Wisconsin offers facilitator training for the Not On Tobacco (N-O-T)® teen cessation program. The facilitator training will prepare individuals to conduct the cessation program using the respective curriculum and materials. Trainings are scheduled on an “as needed” basis, when 10 or more people are interested.

ABOUT THE PROGRAM

The American Lung Association’s Not On Tobacco (N-O-T) program is a state-of-the-art voluntary program specifically designed for teenagers who want to stop smoking. The N-O-T program meets the CDC’s Guidelines for School Health Programs and N-O-T is the only smoking cessation program to have been named a Model Program by SAMHSA (Substance Abuse and Mental Health Services Administration). No other teen smoking cessation program can rival N-O-T’s record of research, evaluation, and success.

COST

The cost of the one-day (8 hour) facilitator training workshop is:

Wisconsin resident: $50.00

Non-Wisconsin resident: $200.00.

The participant fee covers:

• Facilitator Training
• Facilitator Curriculum
• Sample Participant Workbook and additional resources and program materials
• Certificate of participation
• Continental breakfast and lunch
• Free student incentives during program implementation(Wisconsin residents only)
• Access to the NEW National N-O-T Website:

TO BECOME A FACILITATOR, A PERSON MUST:

• Be someone who has not used any tobacco product in the last year
• Be experienced in and comfortable with conducting group programs
• Attend the one-day Not On Tobacco Facilitator Training Workshop conducted by the American Lung Association.
• Complete and abide by the Facilitators Agreement Form
• Conduct at least one N-O-T program per year
• Submit required evaluation components to the American Lung Association

American Lung Association in Wisconsin

13100 W. Lisbon Road, Suite 700, Brookfield, WI. 53005

Phone: (262)703-4200

Fax: (262) 781-5180

Email: