Montgomery County DHHS Narcan Training Registration

Thank you for your interest in attending an upcoming Narcan Training. Please fill out this survey to register for a session. For additional questions, please reach out to the Overdose Response Team at Overdoseresponseprogram@montgomerycountymd.gov

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* 1. Your information

First Name

Last Name

Occupation

ZIP/Postal Code

Email Address

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* 2. Race/Ethnicity(Select all that apply.)

Alaska Native

American Indian

White/Caucasian

Black/African American

Hispanic/Latino

Asian

Native Hawaiian and Other Pacific Islander

Two or More Races

Other

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* 3. Gender

Female

Male

Non binary (Neither, both, so)

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* 4. Age Group

17 years or younger

18-64 years

65+ years

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* 5. What is the reason for attending Narcan Training ?

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* 6. If you are 18 yrs and older and would like to receive a Narcan kit after training, please indicate how you would like to receive it?

Pick up

Ship

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* 7. If you wish to have the kit shipped to you, please provide your shipping address:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Montgomery County DHHS Narcan Training Registration

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* 1. Your information

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* 2. Race/Ethnicity(Select all that apply.)

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* 3. Gender

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* 4. Age Group

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* 5. What is the reason for attending Narcan Training ?

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* 6. If you are 18 yrs and older and would like to receive a Narcan kit after training, please indicate how you would like to receive it?

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* 7. If you wish to have the kit shipped to you, please provide your shipping address:

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* 8. Please select the date of training you would like to attend.