Reward Reminder Data Collection Form
Retail Address Retail Address Correction
Vendor Status:
Out of Business Does Not Sell Tobacco Sells Tobacco
Date: ______Time: ______
Youth Name: ______
Youth Gender: Male or Female Youth Age: 15 16 17
Adult Name: ______
Merchant Gender: Male or Female Merchant Race: ______
Merchant’s Apparent Age:
Under 18 27 - 45 18 – 26 Over 45
Warning Sign Posted Willing to Sell
Yes or No Yes or No
Reward Reminder Visit Program
Code of Conduct
? I will respect the edifice and interior property of all retail locations.
? I will refrain from the use of profanity.
? I will not possess and/or use weapons, tobacco, alcohol, or drugs.
? I will not violate local, state, or federal laws.
? I will not perform Reward Reminders Visits without a designated adult accompanying me.
? My parent/guardian consents to my involvement with ______and the Reward Reminder Visit Program.
Reward Reminder Visit Program
Your signature on this form indicates your consent for your son or daughter to participate in the Reward Reminder Visit Program. This program is part of a statewide campaign to stop the sale of tobacco products to minors.
The purpose of this program is to recognize clerks and retailers who do not sell tobacco products to minors, and remind those who do that it is against the law. Your son or daughter will not be involved in law enforcement.
Participation in this program is voluntary. Your child has the right to stop at anytime.
I understand the following:
? My child may be accompanied and transported by ______staff and/or designated volunteers.
? I agree that no officials or employee associated with ______will be held responsible for any injuries or damages incurred while my child is traveling to or from retail locations. I hereby hold harmless the sponsoring agencies, their officials, divisions and agents against any and all liability, damage, loss claims or demands which arise out of or are in any way connected with my child's participation in the Reward Reminder Visit Program.
I understand the purpose of the Reward Reminder Visit Program and hereby give consent for my son/daughter, ______, to participate in the retail education program.
Parent's Signature: ______
I would like to be an adult volunteer and will accompany my child.
YES____ or NO_____