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2009-2010 N-O-T Application, Vermont N-O-T, Not on Tobacco, Teen Smoking Cessation Program Guidelines and Application 1. Read these guidelines below. 2. Complete the application below and mail to American Lung Association (see mailing address below) or complete application online at www.lungne.org). 3. If you do not have paperwork and student workbooks previous to start of group, contact ALA (see contact information below). 4. Send pre-surveys (All About Me 1) immediately after Session 1 in pre-paid, self-addressed envelope. ALA will issue check 1 (allow up to 30 days). 5. Send post-surveys (All About Me 2) after Session 10 in pre-paid, self-addressed envelope. ALA will issue check 2 (allow up to 30 days). 6. Technical Support: contact Terri Daniels, terri@healthandlearning.org for recruitment and program technical support. Program Guidelines: Facilitators: • Must complete or have previously completed the American Lung Association in Vermont (ALAVT) N-O-T facilitator training prior to start of N-O-T groups. For training schedule and registration, visit http://trainings.healthandlearning.org/ • Must be non-tobacco user for at least six months. Program Implementation: • Facilitators will use the N-O-T program as it was designed without change or alteration. • Program participants must remain anonymous. • Information shared in sessions (unless court mandated) must remain confidential. • The N-O-T program is voluntary, not punitive (i.e., cannot be used in lieu of suspension, ticket or fine for being caught smoking) for youth ages 14-19. • N-O-T group may be no smaller than 4 students to start. Reporting: In order to receive stipend: • Participants’ pre-surveys (All About Me 1) and post-surveys (All About Me 2), completed in Session 1 and Session 10, must be returned to ALAVT upon completion. • Participant attendance form must be returned to ALAVT. What you will receive: Upon approval of the 2009-2010 N-O-T application, schools/organizations will receive: • N-O-T facilitator training (one-day) and curriculum if needed. • Student workbooks, pre and post-surveys, attendance forms, self-addressed, stamped envelopes to return surveys and attendance forms. • Ongoing technical assistance as needed. • A mini-grant of $400.00 per group of 4-5 students or $600 per group of 6 or more students. Funding via check to school/organization to cover additional student incentives and/or facilitator stipend. • Due to limited funds, mini-grant allocation is limited. Make sure you receive your mini-grant by applying for and implementing N-O-T as soon as possible.   Name of site*     Supervisory Union/District (if applicable)     Principal/Director*     Address Line 1*     Address Line 2     City*     State (You must represent a VT school/organization in order to apply)*     Zip Code*     County*     First Name of person completing application*     Last Name of person completing application*     Job Title*     Email Address*     Business Phone*     I have reviewed the N-O-T Guidelines and agree to adhere to program requirements*   Yes   No   Primary N-O-T Facilitator Name (list SAME, if same name as above)     Primary N-O-T Facilitator Email (list SAME, if same email as above)     Primary Facilitator has been trained to facilitate N-O-T   Yes   No   Summer Contact (phone or email)     Secondary N-O-T Facilitator Name (if applicable)     Secondary N-O-T Facilitator Email (if applicable)     Secondary Facilitator has been trained to facilitate N-O-T   Yes   No   Summer Contact (phone or email)     Check box if facilitator has not yet been identified: How would you describe your school/organization? If other, please describe.   public school   private school   residential home   treatment center         Other      Mini Grant   Please make check 1 payable to school and check 2 payable to facilitator   Please make check 1 and check 2 payable to school   Questions? Contact Rebecca Ryan, rryan@lungne.org or 800-LUNG-USA, Option 1, Ext 6862.

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