Instructions: Please complete and submit the form below to apply to become a "Community Access NARCAN® Site" and receive a NARCAN® Emergency Cabinet.

NARCAN® Emergency Cabinets are secure metal units (very similar to publicly sited AED machines), which each contain two doses of NARCAN® nasal spray, along with instructions for its use. When appropriately deployed in specific locations with high rates of opioid overdose, the units are intended to increase access to naloxone during the time of a life-threatening emergency.

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* 1. Site Name:

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* 2. Address:

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* 3. City/Town:

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* 4. ZIP/Postal Code:

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* 5. Hours of Operation:

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* 6. Type of Establishment:

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* 7. Website Address:

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* 8. Contact First Name:

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* 9. Contact Last Name:

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* 10. Contact Phone Number:

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* 11. Contact Email:

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* 12. Number of Cabinets Requested:

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* 13. Confirmation

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* 14. Authorized Representative Signature:

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