Tell Us Your Story

We want to hear from you! If you have a personal story related to tobacco, please share it with us by completing a Testimonial Form. Your story can be a personal account of how tobacco has negatively impacted your life; why you support tobacco control policies in New York City; or another personal story you’d like to share.

Your story can remain anonymous or you can sign up to be a resource for news stories, media interviews, testimony at city council hearings, and many other exciting opportunities to have your voice heard!

How to share your story:

Complete your testimonial in the form below. When you have finished, click the Submit button.

You can also download a pdf version of the testimonial form and return it to the Smoke-Free Partnership in your borough:

Bronx Smoke-Free Partnership 1826 Arthur Ave., Rm. 415 Bronx, NY 10457 gflores@healthsolutions.org	Queens Smoke-Free Partnership 120-34 Queens Blvd., Rm. 419 Kew Gardens, NY 11415 mayon@healthsolutions.org
Brooklyn Smoke-Free Partnership 485 Throop Ave., 1st Fl. Brooklyn, NY 11221 erobinson@healthsolutions.org	Staten Island Smoke-Free Partnership 51 Stuyvesant Place, 2nd Fl. Staten Island, NY 10301 lbrescia@healthsolutions.org
Manhattan Smoke-Free Partnership 158 E. 115th St. New York, NY 10029 jarroyo@healthsolutions.org

Name: *

Phone:

E-mail: *

Address:

date: *

How would you like to be listed in your story?

Please check all that apply:

Include my name in the story

Do not include my name in the story

Include a generic title (please list in the field below - e.g., mother of 3, teacher, principal, Bronx resident, etc.)

generic title:

Testimonial: *

I grant permission to the NYC Coalition For A Smoke-Free City and the Smoke-Free Partnerships to publish my story in its entirety or edited version, with the limitations noted above, and to publish my photo, if furnished, for use in educational fact sheets, brochures, mailings to legislators, distribution to news outlets, advertising and website features. I understand that I am able to withdraw my consent at any time.

If you agree, print your name: *

Attach Photo:

or:

Photo to come by email