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Make a Smokefree Home pledge

I/We pledge to make our home and car completely Smokefree at all times *
  

Is your home already Smokefree?

Already Smokefree
  
I/We would like a free fire safety check and free fire alarm and agree to my name, address and tel number being passed on to South Yorkshire Fire and Rescue service solely for this purpose
  
I/We would like to be referred to the Sheffield NHS Stop Smoking Service
  

Please indicate your ethnicity:

This is optional. Telling us your ethnicity helps us to develop and improve our services.

White
 
 
 
Mixed
 
 
 
 
Asian or Asian British
 
 
 
 
Black or Black British
 
 
 
Other ethnic group
 
 
 

About you

Number of children living at this address (in the following age groups):