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Quit Smoking Month Altogether
The Quitober Challenge 2010 starts in:
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Smokers can get sponsored by their employer to quit smoking during Quitober.

Employers sponsor their staff by:

  • Refunding their $31 membership if they successfully quit during Quitober.
  • Or by simply paying for their staff smokers' membership before the campaign starts.
    *We invoice employer before the campaign for their registered staff smokers.

Discount: Employers that register before the end of Aug get a 10% discount.
how1
Fill out your details below. Your Employer's name should already be selected. You will then be give instructions regards your membership payment if required.
Smoker Contact Details:                            * required
 
*First Name:
*Last Name:
 
*Address:
*Suburb/Town:
 
*State:
*Post Code:
 
*Mobile:
*Tel. (work):
ext.
 
*Email:
*Age:

Employer or Friend Sponsor:  
or ask your employer or friend to >>sponsor you

Questions:
To help us with the evaluation of the Quitober Challenge, please answer the following questions.

1. What gender are you?

Female Male

2. What is the highest level of education completed?

Select one:

Less than high school High school Technical or trade school
College diploma or University degree

3. At what age did you begin to smoke?

years old.

4. On average how many cigarettes do you smoke Daily?

cigarettes

5. How soon after you wake up do you, or did you, smoke?

Within 5 minutes 6-30 minutes 31-60 minutes More than 60 minutes

6. In the last year, how many times did you try to quit?

times. (numbers only)

7. How did you learn about the Quitober Challenge?

Check all that apply:

  Facebook/Twitter Other Social Media Newspapers
  Quit Poster Our Website
  Workplace Cancer Council Health department
  Relative/friend Television Radio  

* I understand and agree to the rules and regulations of the Quitober Challenge.

 

Register > Sponsored Smokers Register


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 







           
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