NRT Participant Agreement Form

Terms of Agreement- Nicotine patches and lozenges are provided free of charge to Rigs without Cigs eligible participants. At SCF, we want to assist you in all ways possible to become tobacco free. If you choose to take advantage of this opportunity to receive free patches and/or lozenges, you agree to the following conditions: • To use the patches and/or lozenges as directed by the manufacturer. • To not smoke while using the patches and/or lozenges. • To not hold the SCF liable for any negative outcomes related to using the patches/lozenges. • To use the patches and/or lozenges until you run out of them (unless there is a medical reason for you discontinue the use of them). • To stay in weekly contact with the Health & Wellness Manager while you are using the patches and/or lozenges. • To reimburse the St. Christopher Fund if you choose not to use the patches and/or lozenges, or if you do not stay in weekly contact with the Health & Wellness Manager.