DON'T PLAY FOR
TEAM BUTTHEAD!
Make
a
promise
to
be
Tobacco
Free
Even if you've made a promise before!
1
I promise to be tobacco free because:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
First Name: ____________________________________
School:_______________________________________
Address: ______________________________________
Last Name:____________________________________
Grade:_______________ Date of Birth: ___/___/_______
Community:___________________________________
Postal Code:___________________________________
Phone: (867) ______ - _________ Male ¨ Female ¨
Email:_________________________________________
Day Month Year
Win!
d
l
u
era
u Co
Choose your incentive
Yo Pro Ca, 2m
014
A Go May 31
You can choose either a sports shirt or a soccer ball.
Check off your choice below.
I want the shirt!
Size: ( ) youth med
( ) youth lg/
adult x-sm
( ) adult sm
( ) adult med
( ) adult lg
2
3
held
Draw
( ) I want the Soccer Ball!
If this is the FIRST TIME you’ ve made a promise, fill out this part
too. By signing below, you are promising to be tobacco free.
___________________________
___________________________
Youth’s Signature
Signature of Parent or Guardian
(if youth is under 12)
Fill in your form completely,
Return it by mail or fax to:
Don't Be a Butthead
Department of Health & Social Services
Box 1320, Yellowknife, NT X1A 2L9
Fax: (867) 873-4330
___________________
Date
You can also fill out your
promise form online at
dontbeabutthead.ca
DON'T PLAY FOR
TEAM BUTTHEAD!
If you would like this information in another official language, contact us at 867-920-3367. Si vous voulez ces informations dans une autre langue officielle, téléphonez-nous au 867-920-3367.
PARENTS - WE NEED
YOU ON OUR TEAM!
It’s time for your child to make a promise to be tobacco
free again... they need to do it each school year!
AS A PARENT, you can help your child say NO to
tobacco even if you are a smoker by:
✔✔ Not using tobacco in your home or vehicle
I Want
YOUR kids
on my team!
✔✔ Talking about the dangers of tobacco use
✔✔ Teaching them how to deal with peer pressure
✔✔ Encouraging them to make a promise
to be tobacco free! Help them fill in this
form or make a promise online
at www.dontbeabutthead.ca
The yearly
promise continues
This year, all youth who make a promise to be tobacco free:
✔✔ receive their choice of a sport shirt or soccer ball
✔✔ have a chance to win a GoPro (draw will be held
May 31, 2014)
If you have questions about Don’t Be a Butthead, call our toll free number at:
1-866-353-0338 or email [email protected]
The personal information requested on this form is collected for the purpose of
administering the Don’t be a Butthead anti-smoking campaign. It is protected by
the privacy provisions of the Access to Information and Protection of Privacy Act.
If you have any questions about its collection or use, please contact
1-866-353-0338 or email [email protected].
BUTTHEAD