Smokefree Homes pledge

By completing this form you have decided to make a fantastic commitment and make your car and/or home smokefree.  You are also protecting those around you from inhaling dangerous levels of secondhand smoke.

Once you have registered we will send you a Smokefree Pack in the post.

1. How did you find out about making a Smokefree Homes pledge?
2. Contact Details
3. How many smokers are in the home?
4. How many children live at this address:
5. We would like to contact you to see how you get on and to enter you into our prize draw, if you are happy with this please tick yes.
6. If you are happy for your details to be passed on the Medway Stop Smoking Service please tick yes.

Thank you for making a Smokefree Pledge!

If you have any questions about this survey or project please contact

Medway Council is committed to compliance with the Data Protection Act 1998, as well as your rights to confidentiality and respect for privacy. The council will ensure that it keeps your personal information accurate and secure to provide you with efficient services.

The Council will only use the information it holds about you for the purpose you provided it. It will also only collect the minimum information necessary to fulfil that purpose. When it no longer has a need to keep information about you, it will be disposed of in a secure manner.

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