Bolton Smoke-Free Homes

Smoke-Free Homes Promise

To make our home a healthier place to live, we are making the following promise:
(Please complete the form below , it will be email to the Smoke-free homes team)

To Make our home a healthier place to live, we are making the following promise:
Gold Promise Silver Promise Bronze Promise

I/We promise to make the house totally smoke-free at all times

I/We promise to allow smoking only in one well ventilated room and never smoke in the presence of the children

I/We promise to never smoke in the presence of the children

Please provide your details: Applicants must be Aged 16 or Older

Name    *

Street Address    *

Address (cont.)

City    *

State/Province

Zip/Postal Code    *

Country

Home Phone *

E-mail
Number of Children in your household aged 1 to 16 *
Number of babies, under one year or expected in your household *
Number of smokers in your household *
Before making your promise, where was smoking allowed in your home?
Nowhere One room Most rooms Everywhere
Before making your promise, did you allow smoking in your car?
Yes No Sometimes Do not have a car
Do you now allow smoking in your car?
Yes No Sometimes Still do not have a car
Are you a smoker?
Yes No
Where did you hear about Bolton's Smoke-Free Homes?
*
Do we have your consent to put your information on a database so that we can send you a questionnaire on our Smoke-Free Home campaign?
Yes No
* must fill fields

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