Texas Youth Tobacco Awareness patrons please submit the court order and student drivers license or identification card to the email address below.
All confidentiality release forms and other documents are to be emailed to
This is a HIPAA compliant, secure and encrypted email account.
Please do not text, fax, or mail any personal information or documents.
Closed week of UTA Spring Break (March 13-17), July 4th, Thanksgiving and Christmas.
ENROLLMENT WILL CONTINUE DURING THESE TIMES.
Texas Youth Tobacco Awareness Program: By Appointment Only.
Call 214.414.6033 to schedule your session. When completing the form
please be aware of the following.
1. Parent name is mandatory in the field.
2. Person name who sent the payment is mandatory in the field (Student should match with person paying, especially if the names are different.)
3. Include an apartment, lot or trailer number if needed.
4. If an address is incorrect, a fee of $5.00 will be assessed for a duplicate certificate and mailing.
5. Please check spelling and all information before submitting form as this is the official information used for completing the certificate and mailing. Thank you kindly. Dr. JiJi.