Public Access to Narcan Event June 2016

Registration Form

Question Title

* 1. Contact Information

Name *

Company

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address

Phone Number *

Question Title

* 2. How did you learn about this event?

Flyer

Facebook

COGI Website

Newspaper

Word of Mouth

Other (please specify)

Question Title

* 3. If you answered "Flyer" to question #3, please indicate location of flyer.

Presentation will be held on Thursday, June 23,, 2016 from 5:30PM - 7:30PM at Hometown Fire Company

You will not receive an email confirmation for your registration, however Survey Monkey should acknowledge your form submission. If you have any questions, please contact COGI at 570-628-6990.