2022 Virtual Kentucky Tobacco Control Conference

First Name

Last Name

Email Address

Organization

Job Title

Please select the county (ies) you serve in your job or volunteer position. If you work statewide, please select 'statewide' instead of selecting individual counties.

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Phone Number

Mailing Address

Photo Release: We may take screenshots or recordings during the conference. Please read the statement below carefully and indicate whether you authorize or do not authorize use of your photographs, etc. I authorize the 2022 KY Tobacco Control Conference, to record my photographs or other images or likenesses in the form of audio, video, or any other medium, or to use, reproduce, modify, distribute, or publicly exhibit such recordings, in whole or in part, for any purpose. Further, I consent to the use of my name, voice, or biographical material in connection with any such recording.