LOCK IT! DROP IT!

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

LOCK IT! DROP IT!

PLEASE TELL OTHERS ABOUT THE CAMPAIGN.
PLEASE CLICK SUBMIT TO SEND THE FORM

Help Prevent Prescription Drug Misuse!

How did you learn about LOCK IT! DROP IT! ? *

Billboard

Partners Against Crime (PAC)

Someone told me (Youth)

Someone told me (Adult)

Other:

First and Last Name, Street Address, City, State, Zip

Required ONLY if you would like a Home Medicine Lock Box

Email Address

Required ONLY if you would like to receive the TRY Prevention TIP each month

I agree to: *

Secure and monitor prescription drugs and meds in my home.

Dispose of expired and/or unused prescription drugs and meds.

Required

Enter your initials below *

Today's Date *

YYYY

Do you have Comments or Questions? Please enter below

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google.