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Toxic Tobacco Request Form

This free assembly is fully funded by the Tobacco Use Prevention Education Grant from the San Diego Unified School District Counseling and Guidance Department. Your school must be on the district approved list and contacted by Mad Science.

Assembly must be conducted by June 15, 2013 and is only for grades 6-8.

Use this form to indicate your assembly prefrences. Once we have received your request, we will send you a confirmation letter via email.

Customer Information
Contact InformationIt is important that we are able to contact you if we have any questions. Please provide a phone number where you can be reached. Your email address will be used to send you a confirmation letter.
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