Naloxone Online Registration Form
DATE: 2nd Tuesday of Month from 6:00 pm - 7:00 pm
4th Monday of Month from 12:00 pm - 1:00 pm
LOCATION: Online Virtual Session
Which Virtual Naloxone Training are you Registering for?
2nd Tuesday of Month from 6:00 pm - 7:00 pm
4th Monday of Month from 12:00 pm - 12:30 pm
Address (must be Wicomico County Resident)
Birthday (Month, Day, Year)
Race / Ethnicity
More than one race
Other: Please check which category best describes your reason for attending
Social Experience (Someone with lived experience or is/has been around friends/associates with lived experience" someone with active or past substance use, or you may know someone that struggles with substance use
Never submit passwords through Google Forms.
This form was created inside of State of Maryland.