Naloxone Kit Request Form

Please complete the following questionnaire to request a free Naloxone (Narcan) kit. Only Licking County residents are eligible to apply. 

Question Title

* 1. Date of request

Date / Time

Question Title

* 2. How old are you?

Question Title

* 3. Do you consider yourself to be male or female?

Question Title

* 4. What race(s)/ethnicity  do you consider yourself? (check all that apply)

Question Title

* 5. Are you requesting this kit as..

T