Two simple steps. That’s all it takes to complete the order form for the FREE Maryland TRASH Quit Kit! And if that seems like a lot to ask, just consider what answering a few questions could mean to a friend or loved one. To ensure proper delivery, please check to make sure ALL of the information you supply is accurate.

Your First Name*

 

Your Last Name*

 

Your Mailing Address 1*

 

Your Mailing Address 2

 

City*

 

Maryland County*
Quit Kit is for Maryland teens only
- Select Your County - Non-Maryland Allegany Anne Arundel Baltimore Baltimore City Calvert Caroline Carroll Cecil Charles Dorchester Frederick Garrett Harford Howard Kent Montgomery Prince George's Queen Anne's Somerset St. Mary's Talbot Washington Wicomico Worchester

 

Zip Code*

 

Contact Phone No.*

 

Contact E-mail*

Please be sure to enter your e-mail address correctly in the required form field. A confirmation e-mail will be sent to you which requires your reply to receive the kit.

 

Your Age Group*

Under the Federal Trade Commission Children's Online Privacy Protection Rule, contact information cannot be collected for youth under 13 years old. If you are under 13 and would like to receive a kit please call us at
(410) 767-5316.

- Select Your Age Group - 12 or younger 13 14 15 16 17 18

 

How did you hear about the Quit Kit?*

 

Please tell us abut how this kit will be used?

 

 

We respect your privacy.The information collected on this form will only be used by Maryland TRASH to improve the Web site experience. We won’t sell your info.

 

By ordering this kit, you acknowledge our right to contact you and the recipient for follow- up.

 

We may occasionally contact you via e-mail to inform you of the movement's activities.