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CORA ORP Trainee Registration Form
This form is for individuals participating in the Overdose Response Training Program. Please fill out the information below, thank you very much!
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* Indicates required question
Please type your full name. (LAST NAME, FIRST NAME)
*
Your answer
Please type your preferred email that we can contact to reach out to you if needed.
*
Your answer
What is the date of your training?
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MM
/
DD
/
YYYY
Sex (optional):
Female
Male
Genderqueer
Non-Binary
Transgender Man
Transgender Woman
Decline to Answer
Other:
Clear selection
Race/Ethnicity (optional) check all that apply:
American Indian or Alaskan Native
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Asian
Are you Hispanic or Latino? (optional)
Yes
No
Clear selection
Age (optional):
Choose
<18
18-24
25-34
35-44
45-54
55-64
65-74
75-84
84+
What population are you are a part of out of these categories? (If you are in HS and living in a particular county, select HS!)
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High School (HS)
College/University (UNI)
Prince George's County (PG)
Other:
Please check which category BEST describes your reason for obtaining overdose education and training (please choose only one).
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Occupation
Volunteer Work
Family Member
Social Experience (for social situations)
Law Enforcement
Have you been trained in overdose response before?
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No, this is my first time!
Yes, and I am getting retrained!
Other:
Would you be interested in receiving biweekly updates from CORA? This includes any additional training or educational opportunities and updates from us.
*
Yes
No
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